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Which of the ff factors makes it important for the nurse to provide special care to older clients with an immune system disorder?
- A. Age-related changes
- B. Use of multiple drugs (Polypharmacy)
- C. Poor diet
- D. Reduced activity levels
Correct Answer: A
Rationale: Age-related changes contribute significantly to the vulnerability of older clients with an immune system disorder. As people age, their immune system undergoes various alterations that can compromise its effectiveness in fighting off infections and diseases. These changes include thymic involution (decrease in thymus size and function), decrease in T-cell production, impaired immune response to infections, and decline in overall immune function. Older individuals are more susceptible to infections due to these age-related changes, which makes it essential for nurses to provide special care tailored to their specific needs. By understanding and considering these age-related immune system changes, nurses can develop appropriate care plans to support the health and well-being of older clients with immune system disorders.
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The nurse is caring for a patient with HIV. Which of the following foods would the nurse teach the patient is safe to eat to reduce the risk of infection?
- A. Raw fruits
- B. Raw vegetables
- C. Cooked vegetables
- D. Caesar dressing
Correct Answer: C
Rationale: For a patient with HIV, it is important to reduce the risk of infection by avoiding potentially contaminated foods. Cooked vegetables are safer to eat compared to raw fruits and vegetables since cooking helps to kill harmful pathogens that can be present on raw produce. Caesar dressing, which typically contains raw eggs, should also be avoided as these can pose a risk of foodborne illness for individuals with compromised immune systems like those with HIV. Therefore, the nurse should teach the patient that cooked vegetables are a safer option for reducing the risk of infection.
While receiving radiation therapy for the treatment of breast cancer, a client complains of dysphagia and skin texture changes, at the radiation site. Which of the following instructions would be most appropriate to suggest to minimize the risk of complications, and promote healing?
- A. Wash the radiation site vigorously with soap and water to remove dead cells.
- B. Eat a diet high in protein and calories to optimize tissue repair.
- C. Apply coo! compresses to the radiation site to reduce edema,
- D. Drink warm fluids throughout the day to relieve discomfort in swallowing
Correct Answer: B
Rationale: Eating a diet high in protein and calories to optimize tissue repair would be the most appropriate instruction to suggest in this scenario. Dysphagia (difficulty swallowing) and skin texture changes can occur as side effects of radiation therapy for breast cancer. Protein is essential for tissue repair, while calories provide the necessary energy for the body to heal. By consuming a diet high in protein and calories, the client can support their body's healing process, minimize the risk of complications, and promote healing at the radiation site. It is important to note that maintaining proper nutrition is crucial during cancer treatment to support overall health and well-being.
What term describes irregular areas of deep blue pigmentation seen predominantly in newborns of African, Asian, Native American, or Hispanic descent?
- A. Acrocyanosis
- B. Erythema toxicum
- C. Mongolian spots
- D. Harlequin color changes
Correct Answer: C
Rationale: Mongolian spots are irregular areas of deep blue pigmentation commonly seen in newborns of African, Asian, Native American, or Hispanic descent. They are flat, benign, and usually appear on the lower back or buttocks, but can also occur on other parts of the body. Mongolian spots are caused by pigment that is trapped deep in the layers of the skin and tend to fade over time, usually by the age of 5 or 6, although they may persist into adulthood in some cases. It is important for healthcare providers to be aware of Mongolian spots to differentiate them from other skin conditions and provide reassurance to parents.
Which screening test is a neonatal nurse likely to use to detect developmental dysplasia of the hip (DDH)?
- A. Barlow's maneuver
- B. Pavlik's maneuver
- C. Gower's maneuver
- D. Allis's maneuver
Correct Answer: B
Rationale: Neonatal nurses are likely to use Pavlik's maneuver to detect developmental dysplasia of the hip (DDH) in newborns. Pavlik's maneuver is a technique used to diagnose, treat, and manage DDH in infants. It involves positioning the infant's hips in a flexed and abducted position to help stabilize the hip joint and promote proper development. This technique is gentle and non-invasive, making it suitable for screening infants for hip dysplasia. Other maneuvers listed, such as Barlow's, Gower's, and Allis's maneuvers, are different techniques used to assess hip stability or alignment and are not specific to DDH screening in newborns.
Nutritional considerations as part of the nursing care plan would include all of the following except that:
- A. The diet should be semisolid to facilitate the passage of food f. Calcium should be avoided g. The patient should be sitting in an upright position during feeding h. Thick fluids should be encouraged to provide additional calories NEUROLOGIC Situation - Richard Gabatan, a 32-year-old car salesman, suffered a spinal cord injury in a motor vehicle accident resulting to paraplegia.
Correct Answer: B
Rationale: It is important to consider calcium supplementation for patients with spinal cord injuries, especially those with paraplegia, as they are at an increased risk of developing osteoporosis due to decreased weight-bearing activities. Calcium is necessary for bone health and should not be avoided in the diet of patients with spinal cord injuries. Therefore, the statement "Calcium should be avoided" is incorrect in this context as it goes against the nutritional considerations that should be included in the nursing care plan for a patient like Richard Gabatan.