Nokea
Which finding on a newborn assessment should the nurse recognize as suggestive of a clavicle fracture?
- A. Negative scarf sign
- B. Asymmetric Moro reflex
- C. Swelling of fingers on affected side
- D. Paralysis of affected extremity and muscles
Correct Answer: C
Rationale: A newborn with a clavicle fracture may present with swelling of the fingers on the affected side. This is due to the injury disrupting the nerves and blood vessels that supply the arm, leading to edema and swelling in the fingers. The other signs mentioned in the options are not typically associated with a clavicle fracture. A negative scarf sign relates to positioning of the arm and is not specific to a clavicle fracture. Asymmetric Moro reflex can be a normal finding in newborns and not indicative of a fracture. Paralysis of the affected extremity and muscles would be more suggestive of a nerve injury rather than a clavicle fracture.
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The nurse knows which of the following statements about TPN and peripheral parenteral nutrition is true?
- A. TPN is usually indicated for clients needing short term (less than 3 weeks) nutritional support, whereas PPN is for long term maintenance
- B. A client needing more than 3000 calories would receive PPN, whereas TPN is given to those requiring less than 3000 calories
- C. TPN is often given to those with fluid restrictions, whereas PPN is used for those without constraints on their fluid intake
- D. TPN is given to those who need to augment oral feeding, whereas PPN is used for those who are nothing by mouth
Correct Answer: C
Rationale: The statement that is true about TPN and peripheral parenteral nutrition (PPN) is that TPN is often given to those with fluid restrictions, whereas PPN is used for those without constraints on their fluid intake. This is because TPN is a hypertonic solution that can cause fluid overload if given in large volumes, so it's typically reserved for patients who have fluid restrictions. On the other hand, PPN is a less concentrated solution that can be safely administered to patients without fluid restrictions.
A few hours before the patient was admitted at the hospital, he complained of fever, nausea and vomiting, and vague abdominal pain. The doctor examined the patient as a case of acute appendicitis and prepared for appendectomy. The nurse anticipates that this type of surgery is classified as:
- A. emergency
- B. urgent
- C. elective
- D. required
Correct Answer: A
Rationale: Appendectomy as a treatment for acute appendicitis is classified as an emergency surgery. Acute appendicitis is considered a medical emergency that requires prompt surgical intervention to prevent complications such as a ruptured appendix, which can lead to peritonitis, a life-threatening condition. In emergency situations, surgery must be done urgently to address the immediate threat to the patient's health. This is in contrast to elective surgeries, which are typically scheduled in advance and do not require immediate attention. In the case described, the patient's symptoms of fever, nausea, vomiting, and vague abdominal pain suggest an acute presentation that necessitates urgent surgical intervention, making it an emergency appendectomy.
Which of the ff is the potential complication the nurse should monitor for when caring for a client with acute respiratory distress syndrome?
- A. Chest wall bulging
- B. Renal failure
- C. Difficulty swallowing
- D. Orthopnea CARING FOR CLIENTS WITH INFECTIOUS AND INFLAMMATORY DISORDERS OF THE HEART AND BLOOD VESSELS
Correct Answer: B
Rationale: Acute respiratory distress syndrome (ARDS) is a serious condition that can lead to various complications, including renal failure. When a client is experiencing ARDS, the lungs become severely inflamed and filled with fluid, which can lead to decreased oxygen levels in the blood. This decrease in oxygen can place a significant strain on the kidneys, potentially resulting in renal failure. Therefore, it is crucial for nurses to monitor the client for signs and symptoms of renal failure, such as changes in urine output, fluid imbalance, electrolyte abnormalities, and altered mental status. Timely detection and management of renal complications in clients with ARDS are essential to prevent further deterioration of the client's condition.
The MOST appropriate answer to why infants cry in response to another infant's cry is
- A. an early sign of empathy development
- B. a sign of good hearing reflex
- C. a startle reflex
- D. an early sign of fear development
Correct Answer: A
Rationale: Empathy begins developing early, though rudimentary.
Mr. Boy, a 65-year old man, has been admitted wth severe flame burns resulting from smoking in bed. The nurse can expect his room environment to include:
- A. strict isolation techniques and policies
- B. a semi-private room
- C. liberal, unrestricted visiting
- D. equipment shared between Mr. Boy and the other burn patients in the unit
Correct Answer: B
Rationale: Mr. Boy, who suffered severe flame burns from smoking in bed, would require specialized care in a burn unit. In such units, patients like Mr. Boy are typically placed in semi-private rooms. This setting allows for close monitoring, infection control, and privacy for the patient to receive specialized care. Semi-private rooms also facilitate the management of burn injuries, including wound care, dressing changes, and overall patient care. Additionally, the environment in a semi-private room helps in preventing the spread of infections and ensures that the patient's specific care needs are met effectively.