Nokea
Tiffany is diagnosed with increased intracranial pressure (ICP); which of the following if stated by her parents would indicate a need for Nurse Charlie to reexplain the purpose for elevating the head of the bed at a 10 to 20-degree angle?
- A. Help alleviate headache
- B. Increase intrathoracic pressure
- C. Maintain neutral position
- D. Reduce intra-abdominal pressure.
Correct Answer: B
Rationale: Elevating the head of the bed at a 10 to 20-degree angle helps to increase intrathoracic pressure. This increase in pressure can aid in promoting cerebrospinal fluid drainage and reducing intracranial pressure. It is important to maintain the correct angle to achieve the desired effect and avoid potential complications. If Tiffany's parents mention this as the reason for elevating the bed, Nurse Charlie should reexplain the purpose to ensure they understand the intended outcome.
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The nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination:
- A. at the end of her menstrual cycle
- B. on the 1st day of the menstrual cycle
- C. on the same day each month
- D. immediately after her menstrual period
Correct Answer: C
Rationale: The nurse should advise the premenopausal woman to perform her breast self-examination on the same day each month. Regular monthly self-examination helps the woman become familiar with the normal texture and appearance of her breasts, making it easier to detect any changes or abnormalities that may indicate a problem. Performing the examination on the same day each month helps ensure consistency in timing and facilitates the woman to establish a routine for self-examination. This consistent approach increases the likelihood of detecting any changes early, which is crucial for timely medical evaluation and intervention if needed.
A 19 y.o. student develops trigeminal neuralgia. Which of the ff. actions will most likely aggravate her pain?
- A. Sleeping
- B. Reading
- C. Eating
- D. Cooking
Correct Answer: C
Rationale: Trigeminal neuralgia is a condition characterized by sudden and severe facial pain caused by irritation or damage to the trigeminal nerve. Trigeminal neuralgia pain is often triggered by certain activities that stimulate the nerve, such as eating, talking, or brushing teeth. The act of chewing and ingesting food can put pressure on the trigeminal nerve, leading to increased pain for individuals suffering from trigeminal neuralgia. Therefore, eating is most likely to aggravate the pain in a 19-year-old student with trigeminal neuralgia.
An infant can move his head from side to side while following a moving object, can lift his head from a prone position 45 degrees off the examining table, smiles when encouraged, and makes cooing sounds. He cannot maintain a seated position. The most likely age of the infant is:
- A. 1 month
- B. 3 months
- C. 6 months
- D. 9 months
Correct Answer: B
Rationale: At 3 months, infants typically develop the ability to lift their heads 45 degrees in prone, follow objects with their eyes, smile responsively, and make cooing sounds. They are not yet able to sit independently.
A parent of a child with glomerulonephritis asks why the urine is discolored. Which is the best response?
- A. It is not uncommon when children take steroids and BP medications.
- B. There is blood in your child's urine, which causes it to be tea-colored.
- C. The urine is concentrated.
- D. A ketogenic diet can cause tea-colored urine.
Correct Answer: B
Rationale: Hematuria (blood in the urine) is a common finding in glomerulonephritis and causes a tea-colored appearance.
A client with diabetes mellitus has a prescription for 5 U-100 regular insulin and 25 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?
- A. Hyperglycemia
- B. Hyperuricemia
- C. Hypoglycemia
- D. Hypochondria
Correct Answer: C
Rationale: The signs and symptoms of headache, sweating, tremor, pallor, and nervousness described in the client suggest hypoglycemia, which is caused by low blood sugar levels. Insulin is a medication used to lower blood sugar levels in individuals with diabetes. In this case, the client has taken a combination of regular insulin and NPH insulin before breakfast, which could have led to a rapid drop in blood sugar levels by the afternoon causing the symptoms described. It is important to treat hypoglycemia promptly by giving the client a fast-acting carbohydrate source, such as glucose tablets or juice, to raise their blood sugar back to a safe level.