Nokea
Which of the ff nursing interventions may reduce hemostasis and decrease the potential for thrombophlebitis for a client with a neurologic disorder?
- A. Remove and reapply elastic stockings
- B. Keep extremities at neutral position
- C. Change the clients position
- D. Use a flotation mattress NEUROMUSCULAR DISORDERS
Correct Answer: B
Rationale: Keeping the extremities at a neutral position for a client with a neurologic disorder can help reduce hemostasis and decrease the potential for thrombophlebitis. This positioning helps maintain proper blood flow and prevents excessive pressure on the veins, which can lead to blood clots. Removing and reapplying elastic stockings, changing the client's position, and using a flotation mattress may have their own benefits, but in this case, keeping the extremities at a neutral position is the most direct and effective intervention to address the issue of hemostasis and thrombophlebitis for a client with a neurologic disorder.
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A client who is HIV positive should have the mouth examined for which oral problem common associated with AIDS?
- A. Halitosis
- B. Creamy white patches
- C. Carious teeth
- D. Swollen lips
Correct Answer: B
Rationale: A client who is HIV positive should have the mouth examined for oral thrush, which presents as creamy white patches on the tongue or lining of the mouth. Oral thrush, caused by the fungus Candida albicans, is a common oral problem associated with AIDS. It is important to detect and treat oral thrush promptly in HIV-positive individuals as it can cause discomfort, difficulty swallowing, and further complications if left untreated. Regular oral examinations and proper oral hygiene practices are essential for managing oral health in individuals living with HIV/AIDS.
Which of the ff should a client with auto immune disorder be advised to avoid?
- A. Resting during the periods of severe exacerbation
- B. Regular exercise during the periods of remission
- C. Being in crowds during the periods of immunosuppression
- D. Humid environment during the periods of remission
Correct Answer: C
Rationale: Clients with autoimmune disorders often experience periods of immunosuppression, where their immune system is compromised and less effective at fighting off infections. Being in crowded places increases the risk of exposure to infectious agents, which can pose a greater threat to individuals with weakened immune systems. It is important for clients with autoimmune disorders to avoid crowds during periods of immunosuppression to reduce the risk of infections and other complications.
Aling Iska, a 78-year old client consults with a hemoglobin and hematocrit levels of 11mg/dl and 32 % respectively. These finding indicates:
- A. nothing because these are normal findings
- B. the nurse should conduct a thorough nutritional assessment
- C. understanding that the client should be advised to have the test repeated in three months
- D. understanding that anemia is a part of the degeneration of the bone marrow
Correct Answer: B
Rationale: Aling Iska's hemoglobin level of 11mg/dl and hematocrit level of 32% are both below the normal range for her age group. These low levels indicate anemia, which is a condition characterized by a decrease in the number of red blood cells or hemoglobin in the blood. Anemia can be caused by various factors, such as nutritional deficiencies (iron, vitamin B12, folate), chronic diseases, or bone marrow problems. In this case, given Aling Iska's advanced age of 78 years, it is essential for the nurse to conduct a thorough nutritional assessment to determine if her anemia is related to any deficiencies that can be addressed through dietary changes or supplementation. It is important to identify the underlying cause of anemia to provide appropriate interventions and prevent further complications.
The long-term complications seen in thalassemia major are associated to which of the following?
- A. Anemia
- B. Growth retardation
- C. Hemochromatosis
- D. Splenomegaly
Correct Answer: C
Rationale: Thalassemia major is a genetic disorder characterized by abnormal hemoglobin production. Individuals with thalassemia major require frequent blood transfusions to manage their anemia, leading to iron overload in the body. Over time, this excess iron can accumulate in various organs such as the liver, heart, and endocrine glands, causing damage and dysfunction. This condition is known as hemochromatosis. Long-term complications of hemochromatosis include liver cirrhosis, heart failure, diabetes, and endocrine disorders. Therefore, the long-term complications seen in thalassemia major are primarily associated with hemochromatosis rather than anemia, growth retardation, or splenomegaly.
Which is the most appropriate nursing intervention for the newborn who is jittery and twitching and has a high-pitched cry?
- A. Monitor blood pressure closely.
- B. Obtain urine sample to detect glycosuria.
- C. Obtain serum glucose and serum calcium levels.
- D. Administer oral glucose or, if newborn refuses to suck, IV dextrose.
Correct Answer: C
Rationale: The most appropriate nursing intervention for the jittery and twitching newborn with a high-pitched cry is to obtain serum glucose and serum calcium levels (Option C). These symptoms are indicative of possible hypoglycemia or hypocalcemia, which are common issues for newborns. Monitoring glucose and calcium levels will help identify and address any imbalances that may be causing these symptoms. Administering glucose (Option D) may be necessary if hypoglycemia is confirmed, but it should be based on the results of blood tests. Monitoring blood pressure (Option A) and obtaining a urine sample to detect glycosuria (Option B) are not the priority interventions in this scenario compared to assessing serum glucose and calcium levels.