Nokea
What is the role of a nurse during scratch test to detect allergies?
- A. Applying the liquid test antigen
- B. Determining the type of allergy
- C. Measuring the length and width of the
- D. Documenting the findings raised wheal
Correct Answer: A
Rationale: The correct answer is A: Applying the liquid test antigen. During a scratch test to detect allergies, the nurse's role is to apply the liquid test antigen onto the skin to observe the body's reaction. This antigen contains potential allergens that may trigger a response in allergic individuals. By applying this antigen, the nurse can assess if the patient develops a raised wheal or redness at the site, indicating an allergic reaction. This step is crucial in identifying specific allergens causing the patient's symptoms. Choices B, C, and D are incorrect as determining the type of allergy, measuring the length and width of the reaction, and documenting the findings are all important steps but do not directly relate to the initial action of applying the test antigen during a scratch test.
You may also like to solve these questions
A client has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, the client asks what dysplasia means. Which definition should the nurse provide?
- A. Presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin
- B. Increase in the number of normal cells in a normal arrangement in a tissue or an organ
- C. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t found
- D. Alteration in the size, shape, and organization of differentiated cells
Correct Answer: D
Rationale: The correct answer is D because dysplasia refers to the alteration in the size, shape, and organization of differentiated cells. Dysplasia is an abnormal growth or development of cells that can be a precursor to cancer. It is characterized by changes in cell size, shape, and organization, which can be seen in Papanicolaou tests.
Choice A is incorrect because it describes an undifferentiated tumor, not dysplasia. Choice B is incorrect as it describes hyperplasia, not dysplasia. Choice C is incorrect as it refers to metaplasia, not dysplasia.
In summary, dysplasia is specifically about the abnormal changes in the appearance and organization of differentiated cells, making choice D the correct definition.
When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed?
- A. Complete
- B. Focused
- C. General
- D. Time-lapse
Correct Answer: B
Rationale: The correct answer is B: Focused. When a nurse inspects a postoperative incision site for infection, they are conducting a focused assessment. This type of assessment is specific to a particular issue or body system, in this case, the incision site. By focusing solely on the incision site, the nurse can thoroughly evaluate for signs of infection, such as redness, swelling, warmth, or discharge.
A: Complete assessments involve a comprehensive evaluation of all body systems and are not necessary for this specific situation.
C: General assessments are broad and not targeted towards a specific issue like infection at an incision site.
D: Time-lapse assessments involve comparing current findings to previous assessments over a period of time, which is not relevant to immediately identifying signs of infection.
In summary, the correct answer is focused because it allows for a detailed evaluation of the incision site specifically for signs of infection, unlike the other options that are either too broad or not relevant to the situation.
Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?
- A. Risk nursing diagnosis
- B. Actual nursing diagnosis
- C. Possible nursing diagnosis
- D. Wellness diagnosis
Correct Answer: B
Rationale: The correct answer is B: Actual nursing diagnosis. An actual nursing diagnosis is validated by the presence of major defining characteristics, such as signs and symptoms exhibited by the patient. This helps in identifying the specific health issues that the patient is currently experiencing. In contrast, a risk nursing diagnosis is focused on potential health problems that the patient may develop in the future. Possible nursing diagnosis involves uncertain or unclear health issues that require further assessment. Wellness diagnosis is aimed at enhancing health and promoting well-being, rather than addressing existing health problems. Therefore, the presence of major defining characteristics is crucial in confirming an actual nursing diagnosis.
The initial neurological symptom of Guilain-Barre Syndrome is:
- A. Absent tendon reflex
- B. Paresthesia of the legs
- C. Dysrhythmias
- D. Transient hypertension Toni a 32 year old mother of two has had multiple sclerosis for 5 years. She is currently enrolled in a school of nursing. Her husband is supportive and helps with care of their preschool sons. Toni has been admitted to the clinical area for diagnostic studies related to symptoms of visual disturbances.
Correct Answer: B
Rationale: Step 1: Guillain-Barre Syndrome (GBS) is characterized by a rapid onset of weakness and tingling sensations in the legs.
Step 2: Paresthesia refers to abnormal sensations like tingling or numbness, which is a common initial neurological symptom of GBS.
Step 3: Absent tendon reflexes may occur in GBS due to muscle weakness but are not typically the initial symptom.
Step 4: Dysrhythmias and transient hypertension are not typical symptoms of GBS and are not associated with its initial presentation.
In summary, choice B is correct as paresthesia of the legs is a hallmark initial neurological symptom of Guillain-Barre Syndrome, while choices A, C, and D are incorrect as they do not align with the typical presentation of GBS.
A client who underwent litholapaxy surgery for removing bladder stones wants to know how long the urethral catheter needs to stay in place. Which of the ff is the correct response?
- A. The catheter should remain in place for 7 days
- B. The catheter should remain in place for 1-2 days
- C. The catheter should remain in place for 2-3 days
- D. The catheter should remain in place for 3-4 days
Correct Answer: B
Rationale: The correct answer is B: The catheter should remain in place for 1-2 days. After litholapaxy surgery, the urethral catheter is typically removed within 1-2 days to prevent infection and promote healing. Keeping the catheter in place for too long can increase the risk of complications such as urinary tract infections. Options A, C, and D suggest longer durations which are not necessary and may lead to unnecessary discomfort and risks for the client. Therefore, the optimal timeframe for catheter removal post-litholapaxy surgery is within 1-2 days.