Nokea
What is the care priority for a newborn with bladder exstrophy and a malformed pelvis?
- A. Change the diaper frequently and assess for skin breakdown.
- B. Keep the exposed bladder open in a warm, dry environment.
- C. Offer formula for growth and fluid management.
- D. Cluster care to allow the child uninterrupted sleep and strength for upcoming surgical repair.
Correct Answer: D
Rationale: Minimizing disturbances (clustering care) helps prevent infection and allows the infant to conserve energy before surgical repair.
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Which of the ff nursing interventions is involved when caring for a client with influenza?
- A. Maintaining airborne transmission
- B. Oxygen administration
- C. Immediate recognition of respiratory
- D. Complete bed rest distress
Correct Answer: C
Rationale: When caring for a client with influenza, immediate recognition of respiratory distress is crucial. Influenza can lead to respiratory complications such as pneumonia, which may result in respiratory distress. Early detection of symptoms such as increased respiratory rate, shortness of breath, and chest pain can help in providing prompt intervention and preventing further complications. Therefore, the nursing intervention involved in caring for a client with influenza is to closely monitor the respiratory status and quickly recognize any signs of respiratory distress. This proactive approach can potentially save the client's life and improve outcomes.
Once admitted to hospital the physician indicates that Mr. Gubatan is a paraplegic. The family asks the nurse what that means. The nurse explains that:
- A. Upper extremities are paralyzed
- B. Both lower and upper extremities are
- C. Lower extremities are paralyzed paralyzed
- D. One side of the body is paralyzed
Correct Answer: C
Rationale: Paraplegia is a condition characterized by the paralysis of both lower extremities. It does not affect the upper extremities or one side of the body specifically. When someone is described as a paraplegic, it means they have lost function and sensation in their lower limbs, usually due to a spinal cord injury or disease affecting the lower part of the spinal cord. This term helps provide a specific understanding of the type and location of the paralysis in the body.
A nurse has completed an assessment on a newborn. Which finding is considered abnormal?
- A. Nystagmus
- B. Profuse drooling
- C. Dark green or black stools
- D. Slight vaginal reddish discharge
Correct Answer: A
Rationale: Nystagmus refers to involuntary and repetitive eye movements. It is considered abnormal in a newborn as it may be a sign of a neurological or visual problem. Therefore, if a nurse observes nystagmus during a newborn assessment, it should be further investigated and discussed with a healthcare provider to determine the underlying cause and appropriate management. Profuse drooling, dark green or black stools, and slight vaginal reddish discharge are common findings in newborns and do not typically indicate a serious health issue.
A client comes to the clinic complaining of weight loss, fatigue, and a low-grade fever. Physical examination reveals a slight enlargement of the cervical lymph nodes. To assess possible causes for the fever, it would be most appropriate for the nurse to initially ask: a."Have you bee sexually active lately?" b, "Do you have a sore throat at the present time?"
- A. "Have you been exposed recently to anyone with an infection?"
- B. "When did you first notice that your temperature had gone up?"
Correct Answer: A
Rationale: When assessing a client with symptoms of weight loss, fatigue, low-grade fever, and lymphadenopathy (enlarged lymph nodes), it is important to investigate potential causes of infection. In this scenario, considering the client's symptoms and signs, asking if they have been exposed recently to anyone with an infection helps in determining the possibility of an infectious etiology for their symptoms. This question can provide valuable information to guide further assessment and diagnostic evaluation.
A child has been diagnosed with enuresis. TCA imipramine (Tofranil) has been prescribed for the child. The nurse understands that this medication is in which category?
- A. Antidepressant
- B. Antidiuretic
- C. Antispasmodic
- D. Analgesic
Correct Answer: A
Rationale: Imipramine (Tofranil) is a tricyclic antidepressant (TCA) that is commonly used to treat enuresis in children. Enuresis is a condition characterized by involuntary urination, especially observed during sleep in children who are old enough to have bladder control. Imipramine works by affecting the balance of certain neurotransmitters in the brain, which helps regulate the bladder and reduce involuntary urination. While imipramine has antidepressant properties, it is also effective in treating enuresis by reducing the frequency of bedwetting episodes.