Nokea
The young mother wanted to know about the motor development APPROPRIATE in a preschooler. Which of the following statements NOT true?
- A. "He can tie shoe lace"
- B. "He can alternate feet when climbing"
- C. "He has not developed good postures"
- D. "He can hop two or more times"
Correct Answer: B
Rationale: The statement that the preschooler can alternate feet when climbing is not true. Typically, preschoolers at this age group are still developing their coordination and may not have mastered the skill of alternating feet while climbing. It is more common for them to use one foot after the other while climbing. This skill usually requires more advanced motor development and coordination, which may come later in the preschool years.
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Which of the following is the central theme of Sr. Calista Roys theory
- A. Self care deficit
- B. Nursing as caring
- C. Adaptation
- D. Transcultural
Correct Answer: C
Rationale: The central theme of Sr. Callista Roy's theory is adaptation. Roy's Adaptation Model focuses on the individual's ability to adapt to internal and external stimuli in order to maintain health and well-being. The theory emphasizes the interconnectedness of the individual and their environment, highlighting the dynamic process of adaptation in response to stimuli. By focusing on adaptation, Roy's theory guides nursing practice in promoting holistic care that supports individuals in adapting to changes and achieving optimal health outcomes.
What is the primary collaborative goal treatment for Ms. C?
- A. Resolve possible dysfunctional family roles as an adolescent
- B. Increase strong desire to eat
- C. Restore normal nutrition and weight
- D. Assist her to increase feelings of control over eating
Correct Answer: C
Rationale: The primary collaborative goal for the treatment of Ms. C should be to restore normal nutrition and weight. This is essential in addressing the potential health issues associated with anorexia nervosa, which is characterized by significantly low body weight and malnutrition. By focusing on restoring normal nutrition and weight, Ms. C can improve her physical health and overall well-being. Resolving possible dysfunctional family roles as an adolescent, increasing the desire to eat, and assisting her to increase feelings of control over eating are important aspects of treatment as well, but the most immediate goal should be to address the physical consequences of anorexia nervosa through restoring normal nutrition and weight.
When a patient develops a temperature of 39.8 degree centigrade after an abdominal surgery with an ongoing blood transfusion, the PACU nurse should notify the surgeon as this may indicate ______.
- A. abdominal tissue injury
- B. on going potential infection
- C. post-anesthesia drug reaction
- D. allergic reaction from blood transfusion
Correct Answer: B
Rationale: A temperature of 39.8 degrees Celsius (103.6 degrees Fahrenheit) in a patient following abdominal surgery and ongoing blood transfusion may indicate an ongoing potential infection. During surgery, the body is exposed to various microorganisms, and the stress of surgery can weaken the immune system, making the patient more susceptible to infections. Blood transfusions also carry a risk of introducing infections if not properly screened. Therefore, in this situation, an elevated temperature may be a sign that an infection is developing, and prompt notification of the surgeon is important for further evaluation and management.
Which of the following actions is appropriate for managing a conscious patient with a foreign object lodged in the eye?
- A. Attempting to remove the object with tweezers.
- B. Rinsing the eye with sterile saline solution.
- C. Applying pressure to the eyelid to dislodge the object.
- D. Placing a bandage over the affected eye.
Correct Answer: B
Rationale: When managing a conscious patient with a foreign object lodged in the eye, the appropriate action is to rinse the eye with sterile saline solution. This helps to flush out the foreign object and reduce the risk of further injury or infection. Attempting to remove the object with tweezers or applying pressure to the eyelid can potentially cause more harm to the eye. Placing a bandage over the affected eye is not beneficial in this situation as it does not address the presence of the foreign object. Rinsing the eye with sterile saline solution is the safest and most effective initial step to take in managing a foreign object lodged in the eye.
A patient presents with recurrent episodes of sudden, severe vertigo lasting hours, accompanied by nausea, vomiting, and nystagmus. Vestibular function tests demonstrate unilateral weakness. Which of the following conditions is most likely responsible for this presentation?
- A. Vestibular neuritis
- B. Benign paroxysmal positional vertigo (BPPV)
- C. Ménière's disease
- D. Acoustic neuroma
Correct Answer: A
Rationale: The patient's presentation of recurrent episodes of sudden, severe vertigo lasting hours, along with nausea, vomiting, nystagmus, and unilateral weakness on vestibular function tests, is most consistent with vestibular neuritis. Vestibular neuritis is an inflammatory disorder of the vestibular nerve, typically viral in origin, leading to acute onset of vertigo. Patients often experience severe vertigo, imbalance, nausea, and vomiting, along with characteristic nystagmus. Unilateral weakness on vestibular function testing supports the diagnosis of vestibular neuritis, as it indicates dysfunction of one vestibular organ. Benign paroxysmal positional vertigo (BPPV) typically presents with brief episodes of vertigo triggered by changes in head position without associated unilateral vestibular weakness. Ménière's disease is characterized by recurrent episodes of vertigo associated with fluctuating hearing loss, tinnitus, and aural fullness, and