Nokea
Which intervention should the nurse implement to maintain the skin integrity of the preterm newborn?
- A. Cleanse skin with a gentle alkaline-based soap and water.
- B. Cleanse skin with a neutral pH solution only when necessary.
- C. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene solution.
- D. Avoid cleaning skin.
Correct Answer: B
Rationale: Preterm newborns have delicate skin that is more susceptible to damage and irritation. Using a neutral pH solution for cleansing helps to maintain the skin's natural acidity and prevent disruption of the skin barrier. It is important to avoid over-bathing or using harsh alkaline-based soaps that can strip the skin of its natural oils and cause dryness or irritation. Cleansing the skin only when necessary helps to protect the fragile skin of preterm newborns and reduce the risk of skin breakdown or injury.
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How many drops per minute should be delivered?
- A. 6
- B. 17
- C. 50
- D. 100
Correct Answer: B
Rationale: The standard drip factor for an IV infusion set is typically 15 drops per milliliter. To calculate drops per minute, you would multiply the flow rate in milliliters per hour by the drip factor and divide by 60 minutes per hour.
The nurse should expect a client with hypothyroidism to report which health concerns?
- A. Increased appetite and weight loss
- B. Nervousness and tremors
- C. Puffiness of the face and hands
- D. Thyroid gland swelling
Correct Answer: C
Rationale: Hypothyroidism is characterized by an underactive thyroid gland that does not produce enough thyroid hormone. This hormonal imbalance can lead to symptoms such as slow metabolism, weight gain, fatigue, cold intolerance, constipation, and puffiness of the face and hands. The slowed metabolic rate can also cause fluid retention, resulting in the characteristic puffiness associated with hypothyroidism. Increased appetite and weight loss are not typical symptoms of hypothyroidism, as the condition is more commonly associated with weight gain. Nervousness and tremors are more indicative of hyperthyroidism, where the thyroid gland is overactive. Thyroid gland swelling, known as goiter, can occur in various thyroid disorders but is not specific to hypothyroidism.
What deficits would the nurse expect in a right-handed person experiencing a stroke affecting the left side of the cortex?
- A. Expressive aphasia and paralysis on the right side of the body.
- B. Expressive aphasia and paralysis on the left side of the body. .
- C. Dysarthria and paralysis on the right side of the body.
- D. Mixed aphasia and paralysis on the right side of the body.
Correct Answer: A
Rationale: In a right-handed individual experiencing a stroke that affects the left side of the cortex, the deficits are typically seen on the opposite side of the body due to the way the brain is wired. This phenomenon is known as contralateral organization. In this scenario, the left side of the brain controls the right side of the body.
The nurse understands that labyrinthitis is treated primarily with which of the ff. drug categories?
- A. Antihistamines
- B. Anti-inflammatories
- C. Antispasmotics
- D. Antiemetics
Correct Answer: A
Rationale: Labyrinthitis is an inner ear disorder that is often caused by a viral infection. Antihistamines are commonly used in the treatment of labyrinthitis to help reduce symptoms such as dizziness, nausea, and vomiting. Antihistamines work by blocking the effects of histamine, which is a chemical in the body that can cause these symptoms. Additionally, antihistamines can help alleviate any associated allergies or inflammation in the inner ear that may be contributing to the condition. Other treatment options for labyrinthitis may include vestibular rehabilitation exercises, antiemetics for nausea and vomiting, and medications to manage dizziness.
The nurse recognizes that the major early problem for Mr. Gabatan will be:
- A. Bladder control
- B. Quadriceps setting
- C. Client education
- D. Use of aids for ambulation
Correct Answer: B
Rationale: The major early problem for Mr. Gabatan will likely be quadriceps setting. Quadriceps setting exercises are important for preventing muscle weakness and atrophy, especially after surgery or prolonged immobility. Strengthening the quadriceps muscles is essential for maintaining proper knee function, stability, and overall mobility. It is a crucial aspect of early rehabilitation and recovery for patients, particularly after orthopedic procedures such as joint replacements or fractures. Maintaining and improving quadriceps strength will also play a significant role in promoting Mr. Gabatan's independence and mobility during his recovery process.