Nokea
Toni's disease process involves a sacral plexus. Assessment should include:
- A. Bladder problems
- B. Sexual activity
- C. Bowel management
- D. All of the above
Correct Answer: D
Rationale: When a patient's disease process involves the sacral plexus, such as in the case of Toni, it is important to assess aspects related to bladder problems, sexual activity, and bowel management. The sacral plexus plays a significant role in controlling functions such as bladder and bowel movements, as well as sexual function. Therefore, a comprehensive assessment including all of these areas is essential to provide holistic care for the patient and address any potential issues related to the sacral plexus involvement.
You may also like to solve these questions
To whom is RhIG (RhoGAM) administered to prevent Rh isoimmunization?
- A. Rh-negative women who deliver an Rh-positive newborn
- B. Rh-positive women who deliver an Rh-negative newborn
- C. Rh-negative newborns whose mothers are Rh positive
- D. Rh-positive fathers before conception of second newborn when first newborn was Rh positive
Correct Answer: A
Rationale: RhIG (RhoGAM) is administered to Rh-negative women who deliver an Rh-positive newborn to prevent Rh isoimmunization. Rh isoimmunization can occur when an Rh-negative mother is exposed to Rh-positive fetal blood during childbirth, leading to the production of antibodies against Rh antigen. RhIG works by binding to and destroying any fetal Rh-positive red blood cells that have entered the mother's circulation, preventing her immune system from mounting an immune response and producing antibodies. This helps to protect subsequent pregnancies from complications related to Rh isoimmunization. Therefore, RhIG administration is crucial in preventing sensitization and ensuring the health of future pregnancies in Rh-negative women who deliver an Rh-positive newborn.
Which is an important nursing consideration in preventing the complications of congenital hypothyroidism (CH)?
- A. Assess for family history of CH.
- B. Assess mother for signs of hypothyroidism.
- C. Be certain appropriate screening is done prenatally.
- D. Be certain appropriate screening is done on newborn.
Correct Answer: D
Rationale: Early detection and prompt treatment are crucial in preventing the complications of congenital hypothyroidism (CH). All newborns should undergo newborn screening tests, including a test for CH. This screening helps to identify infants with CH early on, allowing for timely interventions such as thyroid hormone replacement therapy. Failure to conduct appropriate screening on newborns can lead to delayed diagnosis and treatment, which can result in significant developmental delays and other complications associated with CH. Therefore, ensuring that appropriate screening is done on newborns is a key nursing consideration in preventing the complications of congenital hypothyroidism.
A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. A well-informed new graduate would know the greatest likelihood of an acute hemolytic reaction would occur when giving:
- A. A-positive blood to an A-negative client
- B. O-positive blood to an A-positive client
- C. O-negative blood to an O-positive client
- D. B-positive blood to an AB-positive client
Correct Answer: B
Rationale: The greatest likelihood of an acute hemolytic reaction occurs when there is mismatch in the ABO blood group system, specifically when the recipient's plasma contains antibodies against the donor's red blood cells. In this scenario, giving O-positive blood to an A-positive client presents the highest risk because the A-positive client has anti-B antibodies in their plasma, which can attack the B antigens present on the O-positive donor red blood cells. This mismatch can lead to rapid destruction of the transfused red blood cells, causing an acute hemolytic reaction. It is crucial to ensure ABO compatibility to prevent such life-threatening reactions during blood product transfusions.
Nurse Raymond is giving instructions to an elderly client on diabetic foot care. Which teaching is not part of foot care?
- A. wear comfortable shoes that fit well and protect your feet
- B. trim your toenails straight across and file edges with emery board
- C. wash your feet in hot water to keep feet soft
- D. wear shoes at the beach or on hot pavement
Correct Answer: C
Rationale: Washing your feet in hot water is not recommended for diabetic foot care as it can increase the risk of burns and skin damage due to reduced sensitivity and circulation in the feet. Instead, it is advised to wash your feet in warm water, not hot, and to thoroughly dry them, especially in between the toes, to prevent fungal infections.
When creating a teaching program for the parents of Jessica who is diagnosed with pulmonic stenosis (PS), Nurse Alex would keep in mind that this disorder involves which of the following?
- A. A single vessel arising from both ventricles
- B. Obstruction of blood flow from the left ventricle
- C. Obstruction of blood flow from the right ventricle
- D. Return of blood to the heart without entry to the left atrium
Correct Answer: C
Rationale: Pulmonic stenosis (PS) is a heart condition where there is obstruction or narrowing of the pulmonary valve, which is responsible for allowing blood to flow out of the right ventricle to the lungs for oxygenation. This obstruction leads to decreased blood flow from the right side of the heart to the lungs, causing increased pressure in the right ventricle. This can result in symptoms such as fatigue, shortness of breath, and possible heart murmurs. It is essential for Nurse Alex to educate Jessica's parents about the impact of this obstruction in the right ventricle and the importance of monitoring Jessica's symptoms and seeking appropriate medical care when needed.