Which of the following communication methods is not an option for a patient following laryngectomy surgery?
- A. Placing a finger over the stoma
- B. Using a picture board
- C. Using a special valve that diverts air into
- D. Learning esophageal speech the oesophagus
Correct Answer: B
Rationale: Following laryngectomy surgery, the larynx (voice box) is removed, making it impossible for the patient to produce sound for speech. The options listed are alternative communication methods for patients post-surgery, except for using a picture board. Placing a finger over the stoma can help redirect air for speech, using a special valve can help divert air for speech as well, and learning esophageal speech involves speaking by swallowing air into the esophagus and then releasing it to create sound. Picture boards are not a common method of communication for patients following laryngectomy surgery.
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At a public health fair, the nurse teaches a group of women about breast cancer awareness. Possible signs of breast cancer include:
- A. Fever.
- B. Nipple discharge and a breast nodule.
- C. Breast changes during menstruation.
- D. Fever and erythema of the breast.
Correct Answer: B
Rationale: Possible signs of breast cancer include nipple discharge (especially if it is bloody) and a breast nodule or lump that can be felt. It is important to note any changes in the breasts and report them to a healthcare provider for evaluation. Fever, breast changes during menstruation, and erythema of the breast are not typically associated with breast cancer. It is essential for women to perform regular breast self-exams and seek medical attention if they notice any unusual changes in their breast tissue.
The nurse is caring for a preterm newborn who requires mechanical ventilation for the treatment of respiratory distress syndrome. What is the preterm newborn at increased risk of due to the mechanical ventilation?
- A. Alveolar rupture
- B. Meconium aspiration
- C. Transient tachypnea
- D. Retractions and nasal flaring
Correct Answer: A
Rationale: Preterm newborns who require mechanical ventilation are at increased risk of developing alveolar rupture. The pressure from mechanical ventilation can lead to overdistension of the alveoli, causing damage to their delicate structure. This can result in the rupture of the alveolar walls, leading to a condition known as pulmonary interstitial emphysema. Alveolar rupture can contribute to the development of other complications such as pneumothorax and air leaks, which can further compromise the newborn's respiratory status. Therefore, close monitoring and adjustment of ventilation parameters are crucial in the care of preterm newborns on mechanical ventilation to minimize the risk of alveolar rupture and its associated complications.
Constellation of aniridia and hemihypertrophy is strongly associated with increased risk of which of the following tumors?
- A. rhabdomyosarcoma
- B. hepatoblastoma
- C. Wilms tumor
- D. medulloblastoma
Correct Answer: C
Rationale: Aniridia and hemihypertrophy are features of WAGR syndrome, which increases the risk of Wilms tumor.
Which of the ff is a nursing intervention to ensure that the client is free from injury caused by falls?
- A. Nurse monitors for chest pain and elevated low-density lipoprotein levels
- B. Nurse monitors for swelling and heaviness of legs
- C. Nurse monitors postural changes in BP
- D. Nurse monitors temperature for mild fever
Correct Answer: B
Rationale: Monitoring for swelling and heaviness of legs is a nursing intervention that can help prevent falls. Swelling and heaviness of legs could indicate conditions such as edema or circulation problems, which may increase the risk of falls due to impaired mobility and stability. By identifying these signs early on, the nurse can intervene promptly to address the underlying issues and prevent potential falls. This proactive approach aligns with the goal of ensuring the client is free from injury caused by falls. Monitoring for chest pain and elevated low-density lipoprotein levels, postural changes in BP, or mild fever may be important for overall client care but are not directly related to fall prevention.
Which of the following disorders leads to cyanosis from deoxygenated blood entering the systemic arterial circulation?
- A. Aortic stenosis (AS)
- B. Coarctation of aorta
- C. Patent ductus arteriosus (PDA)
- D. Tetralogy of Fallot
Correct Answer: D
Rationale: Tetralogy of Fallot is a congenital heart defect characterized by four primary abnormalities: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. Due to the pulmonary stenosis, less blood reaches the lungs to be oxygenated, resulting in deoxygenated blood entering the systemic arterial circulation. This leads to cyanosis, which is often referred to as "Tet spells" in these patients. Cyanosis is the bluish discoloration of the skin and mucous membranes caused by the presence of deoxygenated hemoglobin. The other conditions listed do not typically result in deoxygenated blood entering the systemic arterial circulation and causing cyanosis.