Nokea
Which action best explains the main role of surfactant in the neonate?
- A. Assists with ciliary body maturation in the upper airways
- B. Helps maintain a rhythmic breathing pattern
- C. Promotes clearing mucus from the respiratory tract
- D. Helps the lungs remain expanded after the initiation of breathing
Correct Answer: D
Rationale: Surfactant plays a crucial role in the neonate by helping the lungs remain expanded after the initiation of breathing. Surfactant is a substance produced by type II alveolar cells in the lungs that reduces surface tension in the alveoli. By lowering surface tension, surfactant prevents the alveoli from collapsing during expiration, thereby helping the lungs to remain expanded and functional. This function is particularly important in neonates, whose lungs are not yet fully developed and may have difficulty maintaining lung expansion without adequate levels of surfactant. Failure to produce enough surfactant can lead to respiratory distress syndrome in premature infants.
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The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for?
- A. Actinic
- B. Arcus
- C. Asymmetry
- D. Assessment
Correct Answer: C
Rationale: In the ABCD method used to assess skin lesions for possible skin cancer, the letter A stands for Asymmetry. Asymmetry refers to the irregular shape of the lesion when one half of the lesion does not match the other half. Lesions that are symmetrical are less likely to be concerning for skin cancer, while asymmetrical lesions should be further evaluated by a healthcare professional. This characteristic helps in identifying potentially worrisome skin lesions early on for appropriate management.
When a client is receiving blood which of the ff nursing actions is essential to determine if chilling is the result of an emerging complication or of infusing cold blood?
- A. Monitoring the client's temperature before, during, and after transfusion
- B. Documenting the client's temp after the transfusion
- C. Documenting the temp of the blood before the transfusion
- D. Comparing the client's temp with the temp of the blood
Correct Answer: A
Rationale: Monitoring the client's temperature before, during, and after transfusion is essential to determine if chilling is the result of an emerging complication or of infusing cold blood. By consistently monitoring the client's temperature at different points in the transfusion process, healthcare providers can identify any significant changes that may indicate a complication. This allows for timely intervention and appropriate management of any issues related to the blood transfusion. Comparing the client's temperature with the temperature of the blood is important but alone it may not provide a comprehensive assessment of the client's condition during the transfusion process. So, the best course of action is to monitor the client's temperature at various time points to ensure accurate assessment and early detection of any complications.
Which of the ff would describe the discomfort experienced by a client with a tension headache?
- A. A heavy feeling over the frontal region and sensitivity to light
- B. Pressure or steady constriction on both sides of the head
- C. Headache and temporary unilateral paralysis
- D. Vague headache, especially peri orbital
Correct Answer: B
Rationale: Tension headaches are commonly described as a sensation of pressure, tightness, or steady constriction around the head. This discomfort is usually felt on both sides of the head, rather than being localized to one specific area. Unlike migraines which may have a pulsating or throbbing quality, tension headaches are characterized by a continuous dull ache. Sensitivity to light (photophobia) and vague headaches are more commonly associated with migraines, not tension headaches. Temporary unilateral paralysis and peri orbital pain are not typical symptoms of tension headaches.
Mr. RR is to have a brain scanning. Nursing intervention in preparation for this test includes:
- A. Discontinuing any anticonvulsant therapy
- B. Obtaining consent for the treatment
- C. Explaining to Mr. RR that although his head will be supported in place for a period of time, the test will not be painful.
- D. Informing Mr. RR that nausea and headache are frequent following this test
Correct Answer: C
Rationale: The nursing intervention in preparation for a brain scanning test such as an MRI or CT scan should include explaining to the patient (Mr. RR in this case) that although his head will be supported in place for a period of time during the test, the procedure itself will not be painful. Providing this explanation helps to alleviate any anxiety or fear Mr. RR may have about the test and ensures that he feels comfortable and well-informed before the procedure. This communication is key to promoting a positive patient experience and ensuring cooperation during the test. It also helps in managing patient expectations and reducing any potential stress or discomfort during the scanning process.
Mr. Reyes is extremely confused. The nurse provide new information slowly and in small amounts because;
- A. Confusion or delirium can be a defense against further stress
- B. Destruction of brain cells has occurred, interrupting mental activity
- C. Teaching based on information progressing from the simple to the complex
- D. A minimum of information should be given, since he is unaware of surrounding
Correct Answer: A
Rationale: Providing new information slowly and in small amounts to a confused individual, like Mr. Reyes, is important because confusion or delirium can be a defense mechanism against further stress. By giving information gradually, it allows the individual to better absorb and process the information without becoming overwhelmed, which can further exacerbate their confusion. This approach also helps reduce the risk of causing additional stress or agitation in the individual, thus promoting a more conducive environment for cognitive processing and understanding.