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What is an early clinical manifestation of bilirubin encephalopathy in the newborn?
- A. Cognitive impairment
- B. Absence of stooling
- C. Lethargy or irritability
- D. Increased or decreased temperature
Correct Answer: C
Rationale: An early clinical manifestation of bilirubin encephalopathy in a newborn is lethargy or irritability. Bilirubin encephalopathy, also known as kernicterus, is a serious condition that occurs when high levels of unconjugated bilirubin build up in the brain tissues. Initially, the baby may become lethargic or irritable due to the toxic effects of bilirubin on the central nervous system. As the condition progresses, symptoms may include poor feeding, high-pitched crying, muscle tone abnormalities, and eventually may lead to more severe consequences such as seizures and irreversible neurological damage. Prompt recognition and treatment of bilirubin encephalopathy are crucial to prevent long-term complications.
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In teaching a female client who is HIV positive about pregnancy, the nurse would know more teaching is necessary when the client says:
- A. "The baby can get the virus from my placenta."
- B. "I'm planning on starting on birth control pills."
- C. "Not everyone who has the virus gives birth to a baby who has the virus."
- D. "I'll need to have a C-section if I become pregnant and have a baby."
Correct Answer: A
Rationale: Option A indicates a misunderstanding about HIV transmission during pregnancy. In reality, with proper medical care and management during pregnancy and delivery, the risk of transmitting HIV from mother to baby can be significantly reduced but not completely eliminated. The virus can be passed from mother to baby during pregnancy, childbirth, or breastfeeding, but it is not directly from the placenta. This misconception highlights the need for further education and clarification on the modes of HIV transmission from mother to child during pregnancy and delivery. Options B, C, and D all demonstrate understanding and appropriate planning related to HIV and pregnancy.
For a client with low blood volume, what are the implications of decreasing blood pressure and a rapid heart rate?
- A. Compression of blood vessels due to blood loss
- B. Increase in the circulating blood volume
- C. Inadequate renal perfusion
- D. Hypovolemia and shock
Correct Answer: D
Rationale: In a client with low blood volume, a decrease in blood pressure and a rapid heart rate can indicate hypovolemia, which is a condition characterized by a decreased volume of circulating blood. This can lead to inadequate perfusion of vital organs, including the kidneys (choice C), as well as other tissues throughout the body. If left unaddressed, severe hypovolemia can progress to shock, a critical condition where there is inadequate blood flow to meet the body's metabolic demands. This can result in organ dysfunction and potentially life-threatening complications. Therefore, the implications of decreasing blood pressure and a rapid heart rate in a client with low blood volume are indicative of hypovolemia and the potential development of shock.
Which is most descriptive of clinical reasoning?
- A. A simple developmental process
- B. Purposeful and goal-directed
- C. Based on deliberate and irrational thought
- D. Assists individuals in guessing what is most appropriate
Correct Answer: B
Rationale: Clinical reasoning is a complex cognitive process used by healthcare providers to make sound clinical decisions about patient care. It involves the gathering and analyzing of information, as well as the formulation and evaluation of potential treatment options. Clinical reasoning is purposeful in that it is driven by the goal of providing the best possible care for the patient. Healthcare providers use their knowledge, skills, and experience to systematically work through patient problems, identify possible solutions, and make informed decisions. The process is goal-directed, aiming to achieve positive health outcomes for the patient based on the best available evidence and clinical expertise.
A client was brought to the school clinic wuth severe, constant, localized abdominal pain. Abdominal muscles are rigid, and rebound tenderness is present. Peritonitis is suspected. The client is hypotensive and tachycardic. The nursing diagnosis most appropriate to the client's signs/symptoms is:
- A. fluid volume deficit related to depletion of intravascular volume
- B. altered thought process related to toxic effects of elevated ammonia levels
- C. abdominal pain related to increased intestinal peristalsis
- D. altered nutrition: less than body requirements related to malabsorption
Correct Answer: A
Rationale: The client's signs and symptoms point towards a diagnosis of peritonitis, which is an inflammation of the peritoneum lining the abdominal cavity. The presence of severe, constant abdominal pain, rigid abdominal muscles, rebound tenderness, hypotension, and tachycardia are all indicative of peritonitis. These symptoms are typically seen when there is an infection or inflammation in the abdominal cavity, leading to fluid shifting from the intravascular space to the peritoneal cavity. This shifting of fluid results in hypovolemia, causing hypotension and tachycardia.
Which of the following disorders results from a deficiency of factor VIII?
- A. Sickle cell disease
- B. Christmas disease
- C. Hemophilia A
- D. Hemophilia B
Correct Answer: C
Rationale: Hemophilia A, also known as classic hemophilia, is a genetic bleeding disorder caused by a deficiency or dysfunction of clotting factor VIII. Factor VIII is crucial for the blood clotting process, and its deficiency leads to prolonged bleeding episodes, even from minor injuries. Christmas disease, mentioned in the options, refers to Hemophilia B, which results from a deficiency in clotting factor IX, not factor VIII. Therefore, the disorder resulting from a deficiency of factor VIII is Hemophilia A.