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.
You may also like to solve these questions
While assessing for costovertebral angle tenderness, a nurse percusses the area, and the client complains of sharp pain. The nurse interprets this finding as most indicative of which disorder?
- A. Liver enlargement
- B. Ovarian infection
- C. Spleen enlargement
- D. Kidney inflammation
Correct Answer: D
Rationale: When assessing for costovertebral angle tenderness, sharp pain on percussion of the area indicates inflammation of the kidney or paranephric area. The correct technique involves placing one hand over the 12th rib, at the costovertebral angle, and thumping that hand with the ulnar edge of the other fist. The client normally feels a thud and should not experience pain. Ovarian infection, liver enlargement, or spleen enlargement are not associated with the costovertebral angle tenderness. Therefore, the correct answer is kidney inflammation.
While assisting with data collection on a client, a nurse hears a bruit over the abdominal aorta. What action should the nurse prioritize based on this finding?
- A. Document the finding
- B. Palpate the area for a mass
- C. Notify the healthcare provider
- D. Percuss the abdomen to check for tympany
Correct Answer: C
Rationale: Detection of a bruit over the aorta during abdominal assessment may indicate the presence of an aneurysm. The nurse's priority action should be to notify the healthcare provider to further evaluate the situation. Palpating the area or percussing the abdomen could potentially increase the risk of an aneurysm rupture. While documenting the finding is important, the priority is to ensure timely intervention by involving the healthcare provider.
When preparing to assist the healthcare provider in examining a client's skin with the use of a Wood light, what action should the nurse perform?
- A. Darken the room
- B. Obtain informed consent from the client
- C. Obtain a scalpel and a slide for diagnostic evaluation
- D. Obtain medication to anesthetize the skin area before proceeding with the examination
Correct Answer: A
Rationale: When using a Wood light during a skin examination, the room should be darkened to enhance the visibility of fluorescence. The Wood light emits long-wavelength ultraviolet light, highlighting certain skin conditions. Darkening the room aids in better visualization. Obtaining informed consent is a crucial aspect of healthcare but not directly related to using a Wood light. Obtaining a scalpel and a slide is unnecessary for a noninvasive Wood light examination. Anesthetizing the skin area is not required as the procedure is painless and noninvasive.
The client has an order for an IV piggyback of Ceftriaxone 750mg in 50mL D5W to run over 30 minutes. What is the appropriate drip rate?
- A. 100 mL/hr
- B. 150 mL/hr
- C. 200 mL/hr
- D. 50 mL/hr
Correct Answer: A
Rationale: To calculate the drip rate, you need to convert the time from minutes to hours. The formula is (Volume to be infused / Time for infusion in minutes) x (60 minutes / 1 hour). Substituting the values, (50 mL / 30 min) x (60 min / 1 hr) = 100 mL/hr. Therefore, the appropriate drip rate is 100 mL/hr. Choices B, C, and D are incorrect as they do not match the calculated drip rate. Option A, 100 mL/hr, is the correct drip rate for administering Ceftriaxone 750mg in 50mL D5W over 30 minutes.
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.