Nokea
Which of the ff are the symptoms of basilar skull fracture? Choose all that apply
- A. Raccoon eyes
- B. Amnesia
- C. Halo sign
- D. Paresthesia
Correct Answer: A
Rationale: The correct answer is A: Raccoon eyes. Basilar skull fracture can result in periorbital bruising, known as raccoon eyes, due to blood pooling in the soft tissues around the eyes. This occurs because the fracture involves the base of the skull near the orbits.
Choice B: Amnesia is not a typical symptom of basilar skull fracture. Amnesia may occur in head injuries but is not specific to basilar skull fractures.
Choice C: Halo sign is a term used to describe a ring of clear fluid surrounding a blood spot, typically seen in cases of a cerebrospinal fluid leak from the ear or nose, not specific to basilar skull fractures.
Choice D: Paresthesia, which refers to abnormal sensations like tingling or numbness, is not a common symptom of basilar skull fractures. It is more associated with nerve damage rather than fractures involving the base of the skull.
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A client with human immunodeficiency virus (HIV) undergoes intradermal anergy testing using Candida and mumps antigen. During the 3 days following the tests, there is no induration or evidence of reaction at the intradermal injection sites. The most accurate conclusion the nurse can make is:
- A. The client has no previous exposure to the antigens injected
- B. The results demonstrate the client has antibodies to the antigens
- C. The client is immunodeficient and won’t have a skin response
- D. The client isn’t allergic to the antigens and therefore doesn’t react
Correct Answer: C
Rationale: The correct answer is C because a lack of response to intradermal anergy testing suggests an inability to mount a normal delayed-type hypersensitivity response, indicating immunodeficiency. This could be due to conditions such as HIV, which impairs cell-mediated immunity.
Choice A is incorrect because absence of reaction does not necessarily indicate lack of previous exposure to antigens.
Choice B is incorrect as the absence of response doesn't confirm the presence of antibodies.
Choice D is incorrect because anergy testing is not used to assess allergy, but rather to evaluate cell-mediated immunity.
What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?
- A. Wait for the patient to complete the sentence.
- B. Immediately begin showing the patient various objects In the environment.
- C. Leave the room and come back later.
- D. Begin naming various objects that the patient could be referring to.
Correct Answer: A
Rationale: The correct answer is A. Waiting for the patient to complete the sentence is the most appropriate intervention as it allows the patient time to formulate their thoughts and express themselves. It shows patience and respect for the patient's communication process.
B: Immediately showing objects may overwhelm the patient and not allow them to express their thoughts fully.
C: Leaving the room would not address the patient's communication difficulty and could make them feel abandoned or misunderstood.
D: Naming objects for the patient assumes what they are trying to say and may not accurately represent their intended message.
A 19-year-old student develops symptoms of respiratory alkalosis related to an anxiety attack. Which nursing intervention is appropriate?
- A. Make sure his oxygen is being administered as ordered.
- B. Have him breathe into a paper bag.
- C. Place him in a semi-fowler’s position.
- D. Have him do coughing and deep breathing exercises.
Correct Answer: B
Rationale: The correct answer is B: Have him breathe into a paper bag. Breathing into a paper bag helps increase the carbon dioxide levels in the blood, which can help reverse respiratory alkalosis caused by hyperventilation during an anxiety attack. This intervention helps to normalize the blood pH and alleviate symptoms.
Incorrect choices:
A: Making sure oxygen is administered as ordered is not appropriate for respiratory alkalosis due to hyperventilation. Oxygen therapy can worsen the condition by further reducing carbon dioxide levels.
C: Placing the student in a semi-fowler's position does not directly address the primary issue of respiratory alkalosis and anxiety-induced hyperventilation.
D: Coughing and deep breathing exercises may exacerbate the hyperventilation and worsen the respiratory alkalosis rather than alleviate the symptoms.
Which of the ff would help a client with an allergic skin reaction to reduce itching and maintain skin intact? Choose all that apply
- A. Humidifying the environment
- B. Avoiding a skin lubricant
- C. Bathing with a bar soap that contains lye
- D. Wearing cotton gloves, esp during sleep
Correct Answer: D
Rationale: The correct answer is D. Wearing cotton gloves, especially during sleep, helps reduce itching by preventing scratching, which can further irritate the skin. Cotton is a breathable fabric that reduces friction and irritation.
A: Humidifying the environment may help in some cases, but it doesn't directly address the itching or maintaining skin integrity.
B: Avoiding a skin lubricant is not recommended as it can help moisturize the skin and reduce itching.
C: Bathing with a bar soap that contains lye can be harsh and drying, exacerbating the skin reaction.
A client receiving chemotherapy has a nursing diagnosis of Deficient diversional activity related to decreased energy. Which statement indicates an accurate understanding of appropriate ways to deal with this deficit?
- A. “I’ll play card games with my friends.”
- B. “I’ll take a long trip to visit my aunt.”
- C. “I’ll bowl with my team after discharge.”
- D. “I’ll eat lunch in a restaurant everyday.”
Correct Answer: C
Rationale: The correct answer is C because bowling with the team after discharge promotes social interaction and physical activity, addressing both the diversional activity deficit and the decreased energy. Playing card games (A) may not involve physical activity. Taking a long trip (B) may be overwhelming and tiring. Eating in a restaurant daily (D) does not address the need for meaningful activities or social interaction.