Nokea
When should the nurse expect jaundice to be present in a newborn with hemolytic disease?
- A. At birth
- B. During first 24 hours after birth
- C. 24 to 48 hours after birth
- D. 48 to 72 hours after birth
Correct Answer: D
Rationale: In a newborn with hemolytic disease, jaundice typically appears 48 to 72 hours after birth due to the accumulation of bilirubin in the baby's blood. This condition is known as hyperbilirubinemia, which occurs when the liver is still immature and unable to effectively process bilirubin. The breakdown of red blood cells in hemolytic disease leads to an increased production of bilirubin, resulting in jaundice. It is important for healthcare providers to monitor the newborn closely during this time period to ensure appropriate management of the jaundice.
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Alaric was diagnosed with minimal-change nephrotic syndrome; which of the following signs and symptoms are characteristics of the said disorder?
- A. Hypertension, edema, hematuria
- B. Hypertension, edema, proteinuria
- C. Gross hematuria, fever, proteinuria
- D. Poor appetite, edema, proteinuria
Correct Answer: B
Rationale: Minimal-change nephrotic syndrome is a kidney disorder characterized by the presence of proteinuria, which is the excessive loss of protein in the urine. This leads to low levels of protein in the blood, causing edema (swelling) due to fluid accumulation in the tissues. In minimal-change nephrotic syndrome, hypertension (high blood pressure) is not a typical finding. Instead, patients often present with normal blood pressure levels. Additionally, hematuria (presence of blood in the urine) is not a common symptom of this disorder. Therefore, the key signs and symptoms characteristic of minimal-change nephrotic syndrome are edema, proteinuria, and the absence of hypertension.
Mr. Go had a post-kidney transplant. What should the nurse immediately assess?
- A. fluid and electrolyte imbalances
- B. hepatotoxicity
- C. infection
- D. respiratory complications
Correct Answer: A
Rationale: After a kidney transplant, it is essential for the nurse to immediately assess for fluid and electrolyte imbalances in the recipient. The transplanted kidney may take some time to start functioning optimally, and during this period, the body may not be able to regulate fluid and electrolyte balance effectively. Monitoring for signs of fluid overload, electrolyte disturbances, and kidney function is crucial to prevent complications such as dehydration, electrolyte abnormalities, and organ rejection. Early detection of these imbalances allows for prompt intervention and prevention of potential complications.
An adolescent asks the nurse what causes primary dysmenorrhea. The nurse's response should be based on which statement?
- A. It is an inherited problem.
- B. Excessive estrogen production causes uterine pain.
- C. There is no physiologic cause; it is a psychological reaction.
- D. There is a relation between prostaglandins and uterine contractility.
Correct Answer: D
Rationale: Primary dysmenorrhea is painful menstruation that occurs without any underlying gynecological conditions, such as endometriosis. The cause of primary dysmenorrhea is related to the release of prostaglandins during menstruation. Prostaglandins are lipid compounds that act as chemical messengers in the body, causing the uterus to contract and shed its lining during menstruation. High levels of prostaglandins can lead to increased uterine muscle contractions, resulting in pain. Therefore, the nurse should explain to the adolescent that there is a relation between prostaglandins and uterine contractility as the cause of primary dysmenorrhea.
Parents report that they have been giving a multivitamin to their 1-year-old infant. The nurse counsels the parents that which vitamin can cause a toxic reaction at a low dose?
- A. Niacin
- B. B
- C. D
- D. C
Correct Answer: C
Rationale: Vitamin D is a fat-soluble vitamin that can be toxic in high doses, leading to hypercalcemia. Infants are particularly vulnerable to vitamin D toxicity because they have a lower ability to excrete excess vitamin D. Symptoms of vitamin D toxicity include nausea, vomiting, weakness, and kidney problems. Therefore, it is important for parents to avoid giving high doses of vitamin D to infants and always follow healthcare provider recommendations for supplementation.
A client is admitted to the ICU, which laboratory result must be reported immediately to the physician?
- A. Hematocrit 48%
- B. paCO2 38 mm Hg
- C. platelets 18,000
- D. WBC count 8000
Correct Answer: C
Rationale: A platelet count of 18,000 is significantly low, indicating a condition known as thrombocytopenia, which can lead to a risk of bleeding. In a critical care setting like the ICU, low platelet counts need to be addressed urgently to prevent serious complications such as hemorrhage. This result must be reported immediately to the physician so that appropriate interventions, such as transfusion of platelets, can be initiated promptly to manage the patient's condition effectively. Hematocrit, paCO2, and WBC count may also be important parameters to monitor in an ICU patient, but the critically low platelet count poses the most immediate threat to the patient's well-being and requires urgent attention.