Nokea
What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
- A. Wait for the patient to complete the sentence.
- B. Immediately begin showing the patient various objects In the environment.
- C. Leave the room and come back later.
- D. Begin naming various objects that the patient could be referring to.
Correct Answer: A
Rationale: It is crucial to give the patient with aphasia time to complete their sentence. Aphasia can impact a person's ability to find the right words, so allowing them the time to express themselves can be helpful. Rushing or providing excessive cues could lead to frustration and may not allow the patient the opportunity to find the appropriate words on their own. Being patient and giving the individual time to communicate can be empowering and supportive.
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Which is an important nursing action related to the use of tape and/or adhesives on preterm newborns?
- A. Avoid using tape and adhesives until skin is more mature.
- B. Use solvents to remove tape and adhesives instead of pulling on skin.
- C. Remove adhesives with warm water or mineral oil.
- D. Use scissors carefully to remove tape instead of pulling tape off.
Correct Answer: A
Rationale: An important nursing action related to the use of tape and/or adhesives on preterm newborns is to avoid using tape and adhesives until the skin is more mature. Preterm newborns have delicate and fragile skin that is more prone to damage and injury. Using tape and adhesives on immature skin can increase the risk of skin tears, irritations, and damage. It is recommended to wait until the skin matures and becomes less delicate before using tape or adhesives on preterm newborns to prevent skin-related complications.
Toni's disease process involves a sacral plexus. Assessment should include:
- A. Bladder problems
- B. Sexual activity
- C. Bowel management
- D. All of the above
Correct Answer: D
Rationale: When a patient's disease process involves the sacral plexus, such as in the case of Toni, it is important to assess aspects related to bladder problems, sexual activity, and bowel management. The sacral plexus plays a significant role in controlling functions such as bladder and bowel movements, as well as sexual function. Therefore, a comprehensive assessment including all of these areas is essential to provide holistic care for the patient and address any potential issues related to the sacral plexus involvement.
Which clinical manifestation would be seen in a child with chronic renal failure?
- A. Hypotension
- B. Massive hematuria
- C. Hypokalemia
- D. Unpleasant "uremic" breath odor
Correct Answer: D
Rationale: Chronic renal failure is characterized by the buildup of waste products and toxins in the blood due to kidney dysfunction. One common clinical manifestation in children with chronic renal failure is the development of an unpleasant "uremic" breath odor. This odor is often described as a fishy or ammonia-like smell and is a result of the accumulation of urea in the blood, which is normally filtered out by the kidneys. Other common clinical manifestations of chronic renal failure in children may include hypertension, fluid retention, electrolyte abnormalities (such as hyperkalemia rather than hypokalemia), anemia, growth failure, and bone abnormalities.
An elderly client develops severe bone marrow depression from chemotheraphy for cancer of the prostate. The nurse should;
- A. Monitor Intake and output of fluids
- B. Increase dally intake of fluids
- C. Use a soft toothbrush for oral hygiene HEMATOPOIETIC AND LYMPHATIC SYSTEMS
Correct Answer: A
Rationale: Monitoring intake and output of fluids is essential for an elderly client who develops severe bone marrow depression from chemotherapy for prostate cancer. Bone marrow depression can result in decreased production of blood cells, including red blood cells, white blood cells, and platelets. Monitoring intake and output of fluids helps assess hydration status and kidney function. Decreased fluid intake or output may indicate kidney damage or dehydration, which are common concerns in clients with bone marrow depression. Therefore, it is crucial for the nurse to monitor the client's fluid balance closely to ensure optimal functioning of the kidneys and prevent complications related to bone marrow suppression.
Which of the following organisms is the most common cause of urinary tract infection (UTI) in children?
- A. Klebsiella
- B. Staphylococcus
- C. Escherichia coli
- D. Pseudomonas
Correct Answer: C
Rationale: Escherichia coli (E. coli) is the most common cause of urinary tract infections (UTIs) in children. UTIs in children are most commonly caused by bacteria entering the urinary tract through the urethra. E. coli is a type of bacteria that naturally resides in the intestines but can cause infections when it enters the urinary tract. Children, especially girls, are more prone to UTIs due to shorter urethras that make it easier for bacteria to travel up to the bladder. Therefore, E. coli is the most likely culprit in causing UTIs in children.