Nokea
What is most likely to impact the body image of an infant newly diagnosed with Hemophilia?
- A. immobility
- B. altered growth and development
- C. hemarthrosis
- D. altered family processes
Correct Answer: D
Rationale: Altered Family Processes play a significant role in impacting the body image of an infant newly diagnosed with Hemophilia. Infants are highly perceptive of their caregivers' responses, and any changes in family dynamics due to the diagnosis can affect the infant's sense of security and trust, influencing their body image and self-perception. Immobility, while a long-term effect of hemophilia, is not an immediate impact on body image. Altered growth and development would not have manifested immediately post-diagnosis. Hemarthrosis, characterized by bleeding into joint spaces, is a hallmark of hemophilia but does not directly influence body image in the immediate aftermath of a new diagnosis.
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A nurse is preparing to screen a client's vision with the use of a Snellen chart. The nurse uses which technique?
- A. Tests the right eye, then tests the left eye, and finally tests both eyes together
- B. Assesses both eyes together, then assesses the right and left eyes separately
- C. Asks the client to stand 40 feet from the chart and read the largest line on the chart
- D. Asks the client to stand 40 feet from the chart and read the line that can be read 200 feet away by someone with unimpaired vision
Correct Answer: A
Rationale: To test visual acuity with the use of a Snellen chart, the nurse places the chart in a well-lit spot at the client's eye level, with the client positioned exactly 20 feet from the chart. The client shields one eye at a time with an opaque card during the test. After testing each eye separately, both eyes are assessed together. The client is asked to read the smallest line of letters visible and encouraged to read the next smallest line as well. Therefore, option A is correct as it describes the correct technique of testing one eye at a time before assessing both eyes together. Option B is incorrect as it assesses both eyes together first, which is not the standard procedure. Options C and D are incorrect as they suggest standing 40 feet from the chart, which contradicts the standard distance of 20 feet for a Snellen chart test.
The LPN is about to give 100 mg Lopressor (metoprolol) to a client. Before administering the drug, they take the patient's vitals, which are as follows:
Pulse: 58
Blood Pressure: 90/62
Respirations: 18/minute
What action should the LPN take?
- A. Give the client half the prescribed dose and report the findings to the RN on duty.
- B. Give the client double the dose and report the findings to the RN on duty.
- C. Administer the drug and report the findings to the RN on duty.
- D. Hold the drug and report the findings to the RN on duty.
Correct Answer: D
Rationale: Lopressor is given to treat hypertension, and a pulse of 58 and a blood pressure of 90/62 are considered low. To prevent the client from bottoming out, the drug should be held, and the findings reported to the RN, who should consult with the attending physician. LPNs should never adjust client dosing, as that is outside of their scope of practice. It is crucial to follow facility guidelines, which often recommend holding blood pressure medication at 60 bpm and a systolic pressure of 90 or less. By holding the drug and notifying the RN, the LPN ensures the client's safety and allows for appropriate assessment and decision-making by the healthcare team. Giving half the dose or double the dose without proper authorization can lead to serious complications and is considered unsafe practice.
A nurse is preparing to test the function of cranial nerve XI. Which action does the nurse take to test this nerve?
- A. Asking the client to stick out his or her tongue and watching for tremors
- B. Touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex
- C. Depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says 'ah'
- D. Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands
Correct Answer: D
Rationale: To assess the function of cranial nerve XI (spinal accessory nerve), the nurse examines the sternomastoid and trapezius muscles for equal size and strength. The correct method involves asking the client to rotate the head forcibly against resistance to the side of the chin and to shrug the shoulders against resistance from the nurse's hands. Choice A, asking the client to stick out the tongue and watching for tremors, is used to assess cranial nerve XII (hypoglossal nerve). Choice C, depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says 'ah', is the technique for examining cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve). Choice B, touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex, is used to evaluate cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve), not cranial nerve XI.
During a throat assessment, a healthcare provider asks a client to stick out their tongue and notices it protrudes in the midline. Which cranial nerve is being tested?
- A. Cranial nerve X
- B. Cranial nerve V
- C. Cranial nerve IX
- D. Cranial nerve XII
Correct Answer: D
Rationale: The correct answer is cranial nerve XII (hypoglossal nerve). When testing cranial nerve XII, the healthcare provider inspects the symmetry and movement of the tongue. The tongue should protrude in the midline when the client sticks it out. Cranial nerve IX (glossopharyngeal nerve) and X (vagus nerve) are tested by depressing the tongue with a blade to observe pharyngeal movement and gag reflex. Cranial nerve V (trigeminal nerve) is responsible for testing the muscles of mastication, not tongue protrusion.
A community health nurse is instructing a group of female clients about breast self-examination (BSE). The nurse instructs the clients to perform the examination in which manner?
- A. At the onset of menstruation
- B. Every month during ovulation
- C. Weekly, at the same time of day
- D. One week after menstruation begins
Correct Answer: D
Rationale: Breast self-examination (BSE) should be performed after the menstrual period, specifically on the seventh day of the menstrual cycle, when the breasts are smallest and least congested. This timing facilitates the easier detection of any abnormalities. Performing BSE at the onset of menstruation (Option A) can lead to false results due to hormonal changes affecting breast tissue. Performing it every month during ovulation (Option B) is not recommended as breast tissue may be more tender and lumpy during this time. Conducting weekly examinations at the same time of day (Option C) is unnecessary and can lead to unnecessary anxiety for the client.