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Which of the ff. descriptions by the nurse would best explain glaucoma to a patient?
- A. "There is an increase in the amount of vitreous humor."
- B. "There is an increase in the intraocular pressure."
- C. "There is a decrease in the amount of aqueous humor."
- D. "There is a decrease in the intraocular pressure."
Correct Answer: B
Rationale: Glaucoma is a group of eye conditions that damage the optic nerve, usually due to high intraocular pressure (IOP). In glaucoma, there is an imbalance between the production and drainage of aqueous humor in the eye, leading to increased pressure inside the eye. This elevated pressure can cause damage to the optic nerve, which is essential for vision, resulting in vision loss. Therefore, the best description by the nurse to explain glaucoma to a patient would be that there is an increase in intraocular pressure (Choice B).
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Which is an important nursing consideration when caring for an infant with failure to thrive?
- A. Establish a structured routine and follow it consistently.
- B. Maintain a nondistracting environment by not speaking to child during feeding.
- C. Place child in an infant seat during feedings to prevent overstimulation.
- D. Limit sensory stimulation and play activities to alleviate fatigue.
Correct Answer: A
Rationale: Establishing a structured routine and following it consistently is an important nursing consideration when caring for an infant with failure to thrive. Infants with failure to thrive often struggle with feeding, growth, and development. By providing a structured routine, you can create a predictable environment that can help promote the infant's overall well-being. Consistency in feeding times, nap times, and play times can help establish a sense of security and stability for the infant. This routine can also support proper feeding patterns, which are essential for addressing the infant's nutrition needs and promoting growth and development.
The nurse is interviewing the mother of an infant. She reports, "I had a difficult delivery, and my baby was born preterm." This information should be recorded under which of the following headings?
- A. Past history
- B. Present illness
- C. Chief complaint
- D. Review of systems
Correct Answer: A
Rationale: The information given by the mother about having a difficult delivery and her baby being born preterm is considered part of the past medical history. Past medical history includes previous medical conditions, surgeries, hospitalizations, and significant events related to the patient's health before the current encounter. This information helps healthcare providers understand the patient's background and any potential risks or complications relevant to their current health condition.
The nurse is conducting teaching for an adolescent being discharged to home after a renal transplant. The adolescent needs further teaching if which statement is made?
- A. "I will report any fever to my primary health care provider."
- B. "I am glad I only have to take the immunosuppressant medication for two weeks."
- C. "I will observe my incision for any redness or swelling."
- D. "I won't miss doing kidney dialysis every week."
Correct Answer: B
Rationale: The statement "I am glad I only have to take the immunosuppressant medication for two weeks" indicates a misunderstanding about the long-term nature of immunosuppressant therapy following a renal transplant. In reality, individuals who undergo a renal transplant need to take immunosuppressant medications for the rest of their lives to prevent rejection of the donor kidney. Failure to adhere to this medication regimen can result in rejection of the transplanted kidney. Therefore, this statement indicates a need for further teaching to ensure the adolescent understands the importance of lifelong immunosuppressant therapy.
A 5-year old boy presents with afebrile generalized tonic-clonic seizure lasting for 5 minutes. Previously he was healthy and had no such problem. On examination there is no abnormality. Your plan of management should be:
- A. Start anticonvulsant therapy
- B. Request for an EEG and wait for its report
- C. Request for an EEG and start anticonvulsant therapy immediately
- D. Request for EEG and MRI brain
Correct Answer: C
Rationale: In a first-time generalized seizure, an immediate EEG and starting anticonvulsant therapy is prudent to prevent recurrence, especially if the EEG shows epileptiform activity.
The nurse notes vigorous bubbling in the water-seal chamber of a chest-drainage system. Which of the following actions should the nurse take to correct the bubbling?
- A. Examine the entire system and tubing for air leaks.
- B. Lower the level of suction.
- C. Nothing; vigorous bubbling is expected
- D. Ask the patient to cough forcefully.
Correct Answer: A
Rationale: The nurse should examine the entire system and tubing for air leaks when observing vigorous bubbling in the water-seal chamber of a chest-drainage system. Vigorous bubbling indicates that there is air escaping from the system, which can lead to suboptimal drainage and potential complications. By identifying and correcting any air leaks, the nurse can ensure the chest-drainage system functions effectively, allowing for proper drainage and the prevention of complications such as pneumothorax. Lowering the level of suction or asking the patient to cough forcefully would not address the underlying issue of air leaks and may not resolve the problem effectively.