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Where is the best place to observe for the presence of petechiae in dark-skinned individuals?
- A. Face
- B. Buttocks TestBankWorld.org
- C. Oral mucosa
- D. Palms and soles
Correct Answer: C
Rationale: Petechiae are small, pinpoint, red or purple spots on the skin caused by bleeding into the skin. In dark-skinned individuals, it can be challenging to visualize petechiae due to the pigmentation of the skin. However, one of the best places to observe for the presence of petechiae in dark-skinned individuals is the oral mucosa, specifically the inner lining of the mouth. The oral mucosa is usually lighter in color compared to the skin, making it easier to identify petechiae in this area. Palms and soles may also be a good place to observe for petechiae, but the oral mucosa is typically the preferred site for examination in dark-skinned individuals.
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Which of the ff. is a normal hemoglobin value?
- A. 38% to 48%
- B. 48 to 54 mg%
- C. 12 to 18 g/100mL
- D. 27 to 36 g/dL
Correct Answer: C
Rationale: The normal hemoglobin values are typically expressed in grams per deciliter (g/dL) or grams per 100 milliliters (g/100mL) of blood. The range of 12 to 18 g/100mL is considered the normal range for hemoglobin levels in adults. Hemoglobin values outside of this range may indicate various health conditions such as anemia or polycythemia. Option A (38% to 48%) is a range for hematocrit, not hemoglobin. Option B (48 to 54 mg%) and Option D (27 to 36 g/dL) are not within the standard normal range for hemoglobin levels.
Nursing intervention during the lumbar puncture procedure includes:
- A. Monitoring Mrs. GC's color, pulse and respiration
- B. Labeling all laboratory specimens in numerical order
- C. Positioning Mrs. GC on her side with knees drawn up to her chest
- D. All of the above
Correct Answer: C
Rationale: During a lumbar puncture procedure, it is important to position the patient correctly to facilitate the procedure and minimize the risk of complications. Placing the patient on their side with their knees drawn up to their chest helps open up the spaces in the lower spine, making it easier for the healthcare provider to access the appropriate area for the procedure. This position also helps to minimize the risk of post-procedure complications such as spinal headaches. Monitoring the patient's vital signs is important but does not specifically relate to the nursing intervention during the lumbar puncture procedure. Labeling laboratory specimens in numerical order is also a routine task but not directly related to the procedure itself. Thus, the correct intervention during the lumbar puncture procedure is positioning the patient on their side with knees drawn up to the chest.
The child begins to understand right and left by age of
- A. 3 yr
- B. 4 yr
- C. 5 yr
- D. 6 yr
Correct Answer: C
Rationale: Understanding right and left typically develops around age 5.
Which is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery?
- A. Caput succedaneum
- B. Hydrocephalus
- C. Cephalhematoma
- D. Subdural hematoma
Correct Answer: A
Rationale: Caput succedaneum is the vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery. It is often caused by pressure from the vaginal wall during labor. This condition does not involve the calvarial bone and typically resolves on its own within a few days after birth. Hydrocephalus refers to the abnormal accumulation of cerebrospinal fluid within the brain, which can result in an enlarged head circumference. Cephalhematoma is a collection of blood between the periosteum and the skull bone, usually occurring after birth trauma. Subdural hematoma is bleeding between the dura mater and the arachnoid mater surrounding the brain and is typically seen in traumatic head injuries.
A school-age child, admitted for intravenous antibiotic therapy for osteomyelitis, reports difficulty in going to sleep at night. Which intervention should the nurse implement to assist the child in going to sleep at bedtime?
- A. Request a prescription for a sleeping pill.
- B. Allow the child to stay up late and sleep late in the morning.
- C. Create a schedule similar to the one the child follows at home.
- D. Plan passive activities in the morning and interactive activities right before bedtime.
Correct Answer: C
Rationale: Creating a schedule similar to the one the child follows at home will provide familiarity and routine, which can help in establishing a bedtime routine and promoting better sleep. Consistency in sleep schedules is important for children, as it helps regulate their circadian rhythm and promotes quality sleep. By mirroring the child's home schedule, the nurse can create a sense of normalcy and comfort for the child, making it easier for them to fall asleep at bedtime. This approach is non-pharmacological and focuses on promoting healthy sleep habits, which is beneficial for the child's overall well-being and recovery process.