Nokea
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.
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A 2 years old girl presents with blue discoloration of nails and lips. On examination she is cyanosed and clubbed, heart auscultation reveals a short systolic murmur at left upper sternal border. The most likely diagnosis is?
- A. VSD
- B. Tetralogy of Fallot
- C. Tricuspid atresia
- D. Trunchus arteriosus
Correct Answer: B
Rationale: Tetralogy of Fallot typically causes cyanosis, clubbing, and a systolic murmur due to right-to-left shunting.
The parent of a 2-week-old infant, exclusively breastfed, asks the nurse if fluoride supplements are needed. What is the nurse's best response?
- A. "She needs to begin taking them now."
- B. "They are not needed if you drink fluoridated water."
- C. "She may need to begin taking them at age 4 months."
- D. "She can have infant cereal mixed with fluoridated water instead of supplements."
Correct Answer: B
Rationale: The nurse's best response to the parent of a 2-week-old infant, exclusively breastfed, regarding the need for fluoride supplements is that they are not needed if the infant is already drinking fluoridated water. Fluoride supplements are typically recommended for infants who are not receiving enough fluoride through their water source. Breast milk itself does not contain a significant amount of fluoride, but if the family's water supply is fluoridated, the infant will likely receive an adequate amount of fluoride without the need for supplements. It is important for the parent to verify the fluoride content of their water supply with their local water utility to ensure the infant is receiving the appropriate amount of fluoride for dental health.
A highly careful mother of a 10-month-old baby boy complains of inadequate weight gain due to refusal of spoon feeding. The LEAST helpful advice is to
- A. respect infant independence
- B. offer softer diet
- C. use 2 spoons (1 for the child and 1 for the parent)
- D. use finger foods
Correct Answer: B
Rationale: Offering softer food may not address the underlying issue of refusal.
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.
Kasabach-Merritt syndrome is characterized by all the following EXCEPT
- A. thrombocytopenia
- B. microangiopathic hemolytic anemia
- C. coagulopathy
- D. association with infantile hemangiomas
Correct Answer: D
Rationale: Kasabach-Merritt syndrome is not typically associated with hemangiomas.