Nokea
Which of the following is an early sign of anemia?
- A. Palpitations
- B. Pallor
- C. Glossitis
- D. Weight loss
Correct Answer: B
Rationale: Pallor, or paleness of the skin, is an early sign of anemia. Anemia occurs when there is a decrease in the number of red blood cells or the amount of hemoglobin in the blood, resulting in reduced oxygen supply to the body's tissues. This lack of oxygen can cause the skin to appear pale due to decreased blood flow. Other common symptoms of anemia may include fatigue, weakness, shortness of breath, dizziness, and cold hands and feet. Palpitations, glossitis, and weight loss are not typically early signs of anemia.
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Which of the following nursing interventions will help prevent a further increase in ICP?
- A. Encourage fluids
- B. Provide physical therapy
- C. Elevate the head of the bed
- D. Reposition the patient frequently
Correct Answer: C
Rationale: Elevating the head of the bed helps to promote venous drainage from the brain, which can help reduce intracranial pressure (ICP). By positioning the patient with the head of the bed at a 30-45 degree angle, it can facilitate the circulation of cerebrospinal fluid and blood, thus preventing a further increase in ICP. This intervention is a crucial aspect of managing patients with increased ICP and can help improve their overall neurological status.
On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life- threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
- A. Hypocalcemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypermagnesemia
Correct Answer: A
Rationale: Hypocalcemia is the most common electrolyte disturbance that follows thyroid surgery, particularly after a partial thyroidectomy. This occurs due to inadvertent injury or removal of the parathyroid glands, which are responsible for regulating calcium levels in the body. The symptoms of hypocalcemia, such as muscle twitching, hyperirritability of the nervous system, numbness, and tingling, align with the client's presentation in this scenario. Prompt recognition and treatment of hypocalcemia are crucial to prevent life-threatening complications like tetany or seizures. Therefore, the nurse's decision to notify the surgeon immediately is appropriate to address this electrolyte imbalance.
The nurse is taking care of a 2-year-old child with a macule skin lesion. Which clinical finding should the nurse expect to assess with this type of lesion?
- A. Flat, nonpalpable, and irregularly shaped lesion that is greater than 1 cm in diameter
- B. Heaped-up keratinized cells, flaky exfoliation, irregular, thick or thin, dry or oily, varied in size
- C. Flat, brown mole less than 1 cm in diameter
- D. Elevated, flat-topped, firm, rough, superficial papule greater than 1 cm in diameter
Correct Answer: A
Rationale: A macule is a flat, nonpalpable, and discolored area on the skin that is less than 1 cm in diameter. This type of skin lesion is typically characterized by a change in color without any change in texture or thickness of the skin. The clinical finding associated with a macule is a flat, nonpalpable lesion that is smaller in size (less than 1 cm) and regularly shaped. Therefore, the nurse should expect to assess a flat, nonpalpable, and irregularly shaped lesion that is greater than 1 cm in diameter with a different type of skin lesion, not a macule.
The nurse is caring for a school-age child who has had a cardiac catheterization. The child tells the nurse that the bandage is "too wet." The nurse finds the bandage and bed soaked with blood. What is the priority nursing action?
- A. Notify physician
- B. Apply new bandage with more pressure
- C. Place the child in Trendelenburg position
- D. Apply direct pressure above catheterization site
Correct Answer: D
Rationale: The priority nursing action in this situation is to apply direct pressure above the catheterization site to control the bleeding. This is important to prevent excessive blood loss and ensure the child's safety. The nurse should quickly address the issue of the soaked bandage and bed by applying direct pressure to the catheterization site to stop the bleeding. Once bleeding is controlled, the nurse should then notify the physician for further evaluation and treatment. Placing the child in Trendelenburg position is not necessary in this scenario, as the immediate focus should be on controlling the bleeding.
A client diagnosed with DIC is ordered heparin. What is the reason for this medication?
- A. Prevent clot formation
- B. Increase clot formation
- C. Increased blood flow to target organs
- D. Decrease blood flow to target organs
Correct Answer: A
Rationale: Heparin is a medication commonly used to prevent clot formation in various clinical conditions, including Disseminated Intravascular Coagulation (DIC). DIC is a serious condition characterized by abnormal blood clotting and bleeding throughout the body. Heparin works by inhibiting the formation of new clots and preventing the existing clots from further growing, thus helping to manage and prevent complications associated with DIC. By using heparin, the aim is to help stabilize the patient's clotting process and reduce the risk of severe complications such as organ damage or failure.