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Which of the ff would describe the discomfort experienced by a client with a tension headache?
- A. A heavy feeling over the frontal region and sensitivity to light
- B. Pressure or steady constriction on both sides of the head
- C. Headache and temporary unilateral paralysis
- D. Vague headache, especially peri orbital
Correct Answer: B
Rationale: Tension headaches are commonly described as a sensation of pressure, tightness, or steady constriction around the head. This discomfort is usually felt on both sides of the head, rather than being localized to one specific area. Unlike migraines which may have a pulsating or throbbing quality, tension headaches are characterized by a continuous dull ache. Sensitivity to light (photophobia) and vague headaches are more commonly associated with migraines, not tension headaches. Temporary unilateral paralysis and peri orbital pain are not typical symptoms of tension headaches.
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Which factor most impacts the type of injury a child is susceptible to, according to the child's age?
- A. Physical health of the child
- B. Developmental level of the child
- C. Educational level of the child
- D. Number of responsible adults in the home
Correct Answer: B
Rationale: The developmental level of the child most impacts the type of injury they are susceptible to based on their age. As children grow and develop, their physical abilities, cognitive skills, and understanding of the environment change. Younger children may be more susceptible to injuries related to exploration and lack of awareness of dangerous situations, while older children may be more prone to injuries during physical activities or sports. Understanding the developmental stage of a child is crucial in assessing potential risks and implementing appropriate safety measures to prevent injuries.
The nurse is interviewing the mother of an infant. She reports, "I had a difficult delivery, and my baby was born preterm." This information should be recorded under which of the following headings?
- A. Past history
- B. Present illness
- C. Chief complaint
- D. Review of systems
Correct Answer: A
Rationale: The information given by the mother about having a difficult delivery and her baby being born preterm is considered part of the past medical history. Past medical history includes previous medical conditions, surgeries, hospitalizations, and significant events related to the patient's health before the current encounter. This information helps healthcare providers understand the patient's background and any potential risks or complications relevant to their current health condition.
A spica cast was put on Baby Betty after an unfortunate incident to immobilize her hips and thighs; which of the following is the priority nursing action immediately after application?
- A. Keep the cast dry and clean.
- B. Cover the perineal area.
- C. Elevate the cast.
- D. Perform neurovascular checks.
Correct Answer: D
Rationale: Performing neurovascular checks is the priority nursing action immediately after applying a spica cast on Baby Betty. A spica cast is used to immobilize the hips and thighs, which can affect circulation and nerve function in the lower extremities. Neurovascular checks involve assessing the circulation, sensation, and movement of the affected limb to ensure there are no signs of impaired circulation or nerve damage. It is crucial to monitor for any signs of compartment syndrome, such as pain, numbness, tingling, or decreased pulse, which could indicate a vascular compromise. Timely identification of any neurovascular compromise is essential to prevent complications and ensure the baby's safety and well-being.
Which of the following is most important discharge teaching for Mr. Dela Isla
- A. Emergency Numbers
- B. Relaxation technique
- C. Drug Compliance
- D. Dietary prescription SITUATION: Mr. Franco, 70 years old, suddenly could not lift his spoons nor speak at breakfast. He was rushed to the hospital unconscious. His diagnosis was CVA.
Correct Answer: C
Rationale: In the case of Mr. Dela Isla, who suffered a CVA, one of the most important discharge teachings would be drug compliance. Following a stroke, patients are often prescribed medications to help manage their condition and reduce the risk of further complications. It is crucial for Mr. Dela Isla to understand the importance of taking his medications as prescribed by his healthcare provider. Non-compliance with medication regimens can have serious consequences and may increase the likelihood of recurrent strokes or other health issues. Therefore, ensuring that Mr. Dela Isla understands the purpose of his medications, how to take them correctly, and the potential side effects is essential for his recovery and ongoing health management. While emergency numbers, relaxation techniques, and dietary prescriptions are important aspects of care, ensuring drug compliance is critical for the immediate and long-term well-being of a patient who has experienced a stroke.
A client with human immunodeficiency virus (HIV) undergoes intradermal anergy testing using Candida and mumps antigen. During the 3 days following the tests, there is no induration or evidence of reaction at the intradermal injection sites. The most accurate conclusion the nurse can make is:
- A. The client has no previous exposure to the antigens injected
- B. The results demonstrate the client has antibodies to the antigens
- C. The client is immunodeficient and won't have a skin response
- D. The client isn't allergic to the antigens and therefore doesn't react
Correct Answer: C
Rationale: A client with HIV undergoing intradermal anergy testing with Candida and mumps antigens is suspected to be immunodeficient, making them unable to mount a normal skin response to these antigens. In an immunodeficient individual, the immune system is weakened, leading to a lack of response when exposed to these antigens. A lack of induration or reaction in the 3 days following the test suggests that the client's immune system is not able to mount a normal response, indicating immunodeficiency. The absence of a reaction does not necessarily indicate lack of exposure (Option A), presence of antibodies (Option B), or the absence of allergies (Option D), but rather points to a compromised immune system in an individual with HIV.