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Which of the ff. is a symptom that the nurse would expect to find during assessment of a patient experiencing acute angle-closure glaucoma?
- A. Flashing lights
- B. Lens opacity
- C. Halos around lights A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET N
Correct Answer: C
Rationale: Halos around lights are a common symptom observed in patients experiencing acute angle-closure glaucoma. This occurs due to the increased intraocular pressure causing corneal edema, which leads to light scattering and the appearance of halos. Other symptoms may include severe eye pain, redness in the eye, decreased vision, and headache. It is important for the nurse to recognize these symptoms promptly as acute angle-closure glaucoma is a medical emergency that requires immediate treatment to prevent permanent vision loss.
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The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
- A. Breast self-examination
- B. Fine needle aspiration
- C. Mammography
- D. Chest x-ray
Correct Answer: B
Rationale: A diagnosis of breast cancer is confirmed through a biopsy, which involves removing a sample of tissue or cells from the lump in the breast and examining it under a microscope. Fine needle aspiration is a minimally invasive procedure where a thin needle is used to remove cells from the lump for examination. This diagnostic method allows for the confirmation of breast cancer by analyzing the cells for signs of malignancy. While breast self-examinations, mammography, and chest x-rays are important tools for detecting breast abnormalities, they are not definitive in confirming a diagnosis of breast cancer.
Stroking the newborn's cheek along the side of the mouth causes the newborn to turn the head toward that side and begin to suck. This is which reflex?
- A. Perez
- B. Sucking
- C. Rooting
- D. Extrusion
Correct Answer: C
Rationale: The described reflex involving stroking the newborn's cheek along the side of the mouth causing the newborn to turn the head toward that side and begin to suck is known as the rooting reflex. This reflex is essential for newborns to find the nipple and start breastfeeding. Stroking the cheek triggers the baby to turn towards the stimulus, helping them locate the source of food for feeding.
Which of the ff instructions should a nurse give a client with non-Hodgkin's lymphoma who is being treated with radiation and chemotherapy?
- A. Increase fluid intake
- B. Intake low-fat meals
- C. Intake soft, bland foods
- D. Intake food rich in folic acid
Correct Answer: A
Rationale: Patients with non-Hodgkin's lymphoma who are undergoing radiation and chemotherapy need to increase their fluid intake to help flush out the toxic byproducts of the treatments from their body. Adequate hydration can also help prevent dehydration, maintain proper kidney function, and alleviate some side effects such as nausea and vomiting. It is important for the nurse to advise the client to drink plenty of water, clear fluids, and electrolyte-rich beverages to support their overall well-being during treatment.
Which of the following problems associated with anemia best explains why Aisa becomes dizzy during periods of physical activity?
- A. A sudden drop in blood pressure
- B. Insufficient cerebral oxygenation
- C. Decreased level of serum glucose
Correct Answer: B
Rationale: Anemia is a condition characterized by a decreased number of red blood cells or hemoglobin, which can result in inadequate oxygen delivery to tissues and organs, including the brain. When Aisa engages in physical activity, her body's oxygen demand increases. However, due to her anemia, there is a reduced capacity to transport oxygen to meet the increased demand. This mismatch between oxygen supply and demand leads to insufficient oxygen reaching her brain, resulting in dizziness. This symptom is consistent with the explanation of insufficient cerebral oxygenation in the context of anemia.
The physical abuse of children by parents affects children of all ages. It is estimated that 1% to 2% of children are physically abused during childhood and that significant number of them are fatally injured each year. Of the following, the second LEADING cause of mortality from physical abuse is
- A. rib fractures
- B. head trauma
- C. abdominal injury
- D. hot tap water burn
Correct Answer: B
Rationale: Head trauma is a leading cause of mortality in abused children, as it can result in severe brain damage or death.