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Which of the ff is a sign of urinary retention in older adults with a neurologic deficit?
- A. Amnesia
- B. Hypertension
- C. Hypotension
- D. A behaviour change
Correct Answer: D
Rationale: Urinary retention in older adults with a neurologic deficit can lead to a behavior change. This change may manifest as increased restlessness, agitation, or discomfort. It is important to be vigilant for any sudden alterations in behavior as they may indicate underlying complications such as urinary retention, which can be more challenging to identify in older individuals who may have difficulty communicating their symptoms clearly. Monitoring for behavior changes can help healthcare providers promptly address and manage urinary retention in these individuals.
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The nurse is caring for a 32-year old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
- A. Pallor, bradycardia, and reduced pule
- B. Sore tongue, dyspnea, and weight gain
- C. Angina, double vision, and anorexia
- D. Pallor, tachycardia, and a sore tongue
Correct Answer: D
Rationale: Pernicious anemia is a type of megaloblastic anemia caused by the body's inability to absorb vitamin B12, essential for the production of red blood cells. The characteristic findings associated with pernicious anemia include pallor due to decreased red blood cells, tachycardia as the heart compensates for decreased oxygen-carrying capacity, and a sore tongue (glossitis) due to vitamin B12 deficiency affecting the oral mucosa. Therefore, the nurse should expect to find pallor, tachycardia, and a sore tongue when assessing a client with pernicious anemia.
A client diagnosed with DIC is ordered heparin. What is the reason for this medication?
- A. Prevent clot formation
- B. Increase clot formation
- C. Increased blood flow to target organs
- D. Decrease blood flow to target organs
Correct Answer: A
Rationale: Heparin is a medication commonly used to prevent clot formation in various clinical conditions, including Disseminated Intravascular Coagulation (DIC). DIC is a serious condition characterized by abnormal blood clotting and bleeding throughout the body. Heparin works by inhibiting the formation of new clots and preventing the existing clots from further growing, thus helping to manage and prevent complications associated with DIC. By using heparin, the aim is to help stabilize the patient's clotting process and reduce the risk of severe complications such as organ damage or failure.
A nurse is collecting subjective and objective information about target populations to diagnose problems based on community needs. This describes which step in the community nursing process?
- A. Planning
- B. Diagnosis
- C. Assessment
- D. Establishing objectives
Correct Answer: C
Rationale: In the community nursing process, the step of collecting subjective and objective information about target populations to diagnose problems based on community needs is known as "Assessment." This step involves gathering data through observation, interviews, surveys, and other methods to understand the health status, priorities, assets, and resources of the community. This information is essential for identifying the health needs and issues within the community, which then informs the planning and implementation of appropriate interventions. Assessment helps nurses develop a comprehensive understanding of the community's strengths, challenges, and opportunities, enabling them to make informed decisions and tailor interventions to meet the specific needs of the target population.
The Foley Family is caring for their youngest child, Justin, who is suffering from tetralogy of Fallot. Which of the following are defects associated with this congenital heart condition?
- A. Aorta exits from the right ventricle, pulmonary artery exits from the left ventricle, and two noncommunicating circulations
- B. Ventricular septal defect, overriding aorta, pulmonic stenosis (PS), and right ventricular hypertrophy
- C. Coarctation of aorta, aortic valve stenosis, mitral valve stenosis, and patent ductus arteriosus
- D. Tricuspid valve atresia, atrial septal defect, ventricular septal defect, and hypoplastic right ventricle
Correct Answer: B
Rationale: Tetralogy of Fallot is a congenital heart condition characterized by four specific defects:
What is the role of a nurse during scratch test to detect allergies?
- A. Applying the liquid test antigen
- B. Determining the type of allergy
- C. Measuring the length and width of the
- D. Documenting the findings raised wheal
Correct Answer: A
Rationale: During a scratch test to detect allergies, one of the key roles of a nurse is to apply the liquid test antigen onto the patient's skin. The liquid test antigen contains small amounts of common allergens that could trigger a reaction in individuals who are allergic to them. By applying the test antigen onto the skin and creating small scratches or pricks, the nurse can observe if the patient develops a raised, red, itchy bump called a wheal at the site of the allergen exposure. This helps in identifying specific allergies and determining the appropriate treatment plan for the patient.