Nokea
When administering oxygen to a client, under which of the ff situations should the nurse discontinue the administration and notify the physician?
- A. When the client's color does not improve
- B. When the client level of consciousness decreases
- C. When the client is in a state of respiratory arrest
- D. When the client cannot effectively use the diaphragm
Correct Answer: C
Rationale: When a client is in a state of respiratory arrest, it means their breathing has stopped. This is a life-threatening emergency situation that requires immediate action. The nurse should discontinue administering oxygen and promptly notify the physician for further intervention, such as initiating CPR or advanced airway management. Prompt recognition and timely response to respiratory arrest are crucial in saving the client's life.
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As part of primary cancer prevention program, an oncology nurse answers questions from the public at health fair. When someone asks about the laryngeal cancer, the nurse should explain that:
- A. Laryngeal cancer is one of the most preventable types of cancer
- B. Inhaling polluted air isn't a risk factor for laryngeal cancer
- C. Laryngeal cancer occurs primarily in women
- D. Adenocarcinoma accounts for most cases of laryngeal cancer
Correct Answer: A
Rationale: Laryngeal cancer is indeed one of the most preventable types of cancer. The primary risk factors for laryngeal cancer include tobacco use (particularly smoking) and excessive alcohol consumption. Therefore, avoiding tobacco products, moderating alcohol intake, and maintaining a healthy lifestyle can significantly reduce the risk of developing laryngeal cancer. Additionally, early detection through regular check-ups and screenings can help in detecting any precancerous or cancerous changes in the larynx, leading to better treatment outcomes and prognosis.
What should the client at risk for developing AIDS be advised to do?
- A. Abstain from anal intercourse
- B. Have a semen analysis done
- C. Have an ELISA test for antibodies
- D. Inform all sexual contacts
Correct Answer: C
Rationale: The client at risk for developing AIDS, which is caused by the Human Immunodeficiency Virus (HIV), should be advised to have an ELISA test for antibodies to check for the presence of the virus. ELISA is a standard blood test used for HIV screening because it can detect antibodies produced by the body in response to HIV infection. Early detection through testing is crucial to initiate treatment interventions and prevent further transmission of the virus. It is important for the client to undergo this test to determine their HIV status and receive appropriate medical care and support.
During a routine examination of a 10-mo-old male infant, you find a white pupillary reflex of the right eye; the eye movements are normal. You suspect retinoblastoma. Of the following, the BEST confirmatory diagnostic evaluation of this infant is
- A. indirect ophthalmoscopy with slit-lamp examination
- B. examination under general anesthesia by an experienced ophthalmologist
- C. orbital ultrasonography
- D. brain MRI
Correct Answer: B
Rationale: Examination under anesthesia by an experienced ophthalmologist is the gold standard for diagnosing retinoblastoma.
The nurse is assessing a 3-month-old during a well-baby visit. Which of the following findings would warrant the nurse to recommend that the baby have an ultrasound for a possible diagnosis of developmental dysplasia of the hip (DDH)?
- A. Bilateral plantar flexion
- B. Unequal knee heights
- C. Bilateral polydactyly
- D. Positive Babinski test 113
Correct Answer: B
Rationale: Developmental dysplasia of the hip (DDH) is a condition where the hip joint does not develop normally. It is important to detect DDH early in infants as it can lead to long-term hip problems. One of the key physical exam findings that may suggest DDH is unequal knee heights when the infant's legs are flexed. This is known as the Galeazzi sign, and it can indicate hip dysplasia or dislocation. Therefore, if a nurse observes this finding during an assessment of a 3-month-old infant, it would warrant recommending an ultrasound to further evaluate for possible DDH. Bilateral plantar flexion, bilateral polydactyly, and a positive Babinski test are not typically associated with DDH.
Correct method of mouth to mouth respiration is that the victim's chin is held:
- A. Forward
- B. Backward
- C. Sideward
- D. Downward
Correct Answer: D
Rationale: When performing the correct method of mouth-to-mouth respiration, it is essential to ensure that the victim's chin is held downward. This helps to properly open the airway, allowing for effective ventilation. By tilting the head back and holding the chin downward, you are able to align the victim's airway to allow the entry of air into the lungs during rescue breathing. Holding the chin in a downward position also helps prevent any obstruction that may hinder the flow of air. Remember to also pinch the victim's nose closed while giving breaths to ensure that the air goes into their lungs.