Nokea
The patient asks the nurse, "What is hypertension?" Which of the following is the best response to explain hypertension?
- A. "It is measured as the heart pumps blood into the arteries."
- B. "It is higher than normal on two separate occasions."
- C. "It is regulated by stress, activity, and emotions."
- D. "It is determined by peripheral vascular resistance."
Correct Answer: B
Rationale: Hypertension, also known as high blood pressure, is a condition where the force of blood against the walls of the arteries is consistently too high. The definition provided in choice B, "It is higher than normal on two separate occasions," accurately captures the concept of hypertension. A diagnosis of hypertension typically requires blood pressure measurements to be consistently elevated on at least two separate occasions to rule out temporary spikes in blood pressure. This distinction is essential in diagnosing and managing hypertension effectively to prevent complications such as heart disease, stroke, and kidney problems. Choices A, C, and D do not capture the defining characteristic of hypertension as clearly as choice B.
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On a visit to the gynecologist, a client complains of urinary frequency, pelvic discomfort, and weight loss. After a complete physical examination, blood studies, and a pelvic examination with a Papanicolaou test, the physician diagnoses stage IV ovarian cancer. The nurse expects to prepare the client for which initial treatment?
- A. Radiation therapy
- B. Chemotherapy
- C. Major surgery
- D. None
Correct Answer: C
Rationale: In the case of stage IV ovarian cancer, initial treatment typically involves major surgery, known as cytoreductive surgery or debulking surgery. The goal of this surgery is to remove as much of the tumor burden as possible from the abdomen and pelvis. By reducing the size of the tumor, the effectiveness of subsequent treatments such as chemotherapy can be enhanced. Surgery may also involve the removal of the uterus, ovaries, fallopian tubes, and surrounding tissue. Radiation therapy or chemotherapy may be used after surgery to further target any remaining cancer cells. However, major surgery is often the first step in the management of advanced ovarian cancer.
The nurse observes that a new mother avoids making eye contact with her newborn. The nurse should perform which action?
- A. Examine newborn's eyes for ability to focus.
- B. Assess for other attachment behaviors.
- C. Recognize this as a common reaction in new mothers.
- D. Ask mother why she won't look at newborn.
Correct Answer: B
Rationale: The nurse should assess for other attachment behaviors when a new mother avoids making eye contact with her newborn. This behavior may indicate difficulty forming an emotional bond with the newborn, which can impact the mother-infant relationship. By assessing for other attachment behaviors, the nurse can gather more information to understand the mother's response and provide appropriate support and interventions. Simply recognizing this as a common reaction or asking the mother why she won't look at the newborn may not address the underlying attachment issues that may be present. Examining the newborn's eyes for ability to focus is not relevant in this situation and does not address the mother's behavior.
For a 14-month-old whose cleft palate was repaired 12 hours ago, which should be included in the plan of care?
- A. Allow familiar comfort items (e.g., favorite stuffed animal) and a 'sippy' cup (avoid suction items).
- B. Once liquids are tolerated, encourage a bland diet (e.g., soup, Jell-O, saltine crackers).
- C. Administer scheduled pain medication rather than PRN only.
- D. Use a Yankauer suction catheter to decrease aspiration risk.
Correct Answer: A
Rationale: Providing comfort items and avoiding suction items helps reduce distress and supports healing.
Kim is using bronchodilators for asthma. The side effects of these drugs that you need to monitor this patient for include:
- A. tachycardia, nausea, vomiting, heart palpitations, inability to sleep, restlessness, and seizures.
- B. tachycardia, headache, dyspnea, temp. 101 F, and wheezing.
- C. blurred vision, tachycardia, hypertension, headache, insomnia, and oliguria.
- D. restlessness, insomnia, blurred vision, hypertension, chest pain, and muscleweakness.
Correct Answer: A
Rationale: Bronchodilators are medications used to relax and open the airways in the lungs, making it easier to breathe for patients with conditions like asthma. Common side effects of bronchodilators that need to be monitored in patients include tachycardia (increased heart rate), nausea, vomiting, heart palpitations, inability to sleep, restlessness, and in severe cases, seizures. These side effects can vary depending on the type of bronchodilator being used, but it is important for healthcare providers to monitor patients for these symptoms and adjust their treatment as needed.
The parents of a newborn with a strawberry hemangioma ask the nurse what the treatment will be. What information does the nurse need to include in the response?
- A. Excision of the lesion will be necessary.
- B. Injections of prednisone into the lesion will reduce it.
- C. No treatment is usually necessary because of the high rate of spontaneous involution.
- D. Pulsed dye laser treatments will be necessary immediately to prevent permanent disability.
Correct Answer: C
Rationale: The correct information the nurse should provide to the parents is that no treatment is usually necessary for a strawberry hemangioma because of the high rate of spontaneous involution. Strawberry hemangiomas are common vascular tumors in infants that typically appear in the first few weeks of life. They usually grow rapidly for the first several months and then begin to shrink and eventually disappear on their own. In most cases, the hemangioma resolves without the need for any intervention. Therefore, reassuring the parents that observation is the primary management approach is important, unless complications such as ulceration, bleeding, or obstruction occur.