Nokea
Which is the most appropriate vision acuity test for a child who is in preschool?
- A. Cover test
- B. Ishihara test
- C. HOTV chart
- D. Snellen letter chart
Correct Answer: C
Rationale: The HOTV chart is the most appropriate vision acuity test for a child who is in preschool. The HOTV chart is specifically designed for young children who may not yet know their letters. It uses simple shapes (H, O, T, V) instead of letters for visual acuity testing, making it more suitable and engaging for preschool-aged children. This chart allows for an accurate assessment of a child's visual acuity even before they are able to recognize letters, ensuring early detection of any vision problems that may affect their learning and development. The other options, such as the Cover test, Ishihara test, and Snellen letter chart, are more commonly used for older children and adults.
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A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that adaptive immunity is provide by which type of white blood cell?
- A. Neutrophil
- B. Monocyte
- C. Basophil
- D. Lymphocyte
Correct Answer: D
Rationale: Lymphocytes are the type of white blood cells that provide adaptive immunity. There are two main types of lymphocytes: B cells and T cells. B cells produce antibodies that can specifically recognize and target certain pathogens (including HIV), while T cells have various functions in the immune response, such as directly killing infected cells or helping other immune cells. Adaptive immunity is characterized by the body's ability to remember specific pathogens and mount a targeted response upon subsequent exposures. In the context of HIV and AIDS, understanding the role of lymphocytes in adaptive immunity is essential for the client to comprehend how the virus affects the immune system and why immune function becomes compromised over time.
While caring for a patient who is hospitalized for acute gastroenteritis and dehydration, the pediatric nurse notes that the patient's parent keeps packets of herbs by the patient's bedside. Suspecting that the parent may be administering the herbs to the patient, the nurse's first action is to:
- A. ask the parent in a nonjudgmental manner about the herbs.
- B. coordinate a nursing care conference to discuss the patient's plan of care.
- C. discuss the risks of using alternative therapies with the parent.
- D. refer the family to a social worker for possible nonadherence with the healthcare regimen.
Correct Answer: A
Rationale: A nonjudgmental approach encourages open communication and allows the nurse to assess the situation appropriately.
For a client with low blood volume, what are the implications of decreasing blood pressure and a rapid heart rate?
- A. Compression of blood vessels due to blood loss
- B. Increase in the circulating blood volume
- C. Inadequate renal perfusion
- D. Hypovolemia and shock
Correct Answer: D
Rationale: In a client with low blood volume, a decrease in blood pressure and a rapid heart rate can indicate hypovolemia, which is a condition characterized by a decreased volume of circulating blood. This can lead to inadequate perfusion of vital organs, including the kidneys (choice C), as well as other tissues throughout the body. If left unaddressed, severe hypovolemia can progress to shock, a critical condition where there is inadequate blood flow to meet the body's metabolic demands. This can result in organ dysfunction and potentially life-threatening complications. Therefore, the implications of decreasing blood pressure and a rapid heart rate in a client with low blood volume are indicative of hypovolemia and the potential development of shock.
Fentanyl is used as analgesia during operative and postoperative procedures. Which of the following conditions is NOT associated with fentanyl use?
- A. Tachycardia
- B. Hypotension
- C. Nausea and vomiting
- D. Acidosis
Correct Answer: D
Rationale: Fentanyl typically causes hypotension, nausea, and vomiting, but it does not cause acidosis.
How does nosocomial pneumonia occur?
- A. In a healthcare setting
- B. Within 48hrs of admission to a healthcare
- C. In the immunocompromised host facility
- D. In a community setting
Correct Answer: A
Rationale: Nosocomial pneumonia occurs in a healthcare setting. It is a type of pneumonia that is contracted during a hospital stay or other healthcare facilities. The risk of developing nosocomial pneumonia is higher in patients who are already hospitalized due to various medical conditions, surgeries, or use of medical devices like ventilators. The infection can be caused by different types of bacteria, viruses, or fungi present in the healthcare environment. Preventive measures, such as proper hand hygiene, infection control practices, and minimizing the use of invasive devices, are crucial in reducing the incidence of nosocomial pneumonia.