Nokea
Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?
- A. Wilma places 2 fingers between the tie and neck
- B. The tracheotomy can be pulled slightly away from the neck
- C. James' neck veins are not engorged
- D. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process
Correct Answer: A
Rationale: Placing 2 fingers between the tracheostomy tie and the neck is a reliable method to ensure that the tie is not too tight. This technique allows for proper circulation around the neck area and helps prevent skin irritation or pressure ulcers from developing. It strikes a balance between securing the tracheostomy in place and maintaining the patient's comfort and safety. Checking for appropriate tightness by using the finger method is a standard practice in tracheostomy care to prevent complications related to excessive pressure or constriction.
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The nurse has determined the rate of both the child's radial pulse and heart. What is the normal finding when comparing the two rates?
- A. Are the same
- B. Differ, with heart rate faster
- C. Differ, with radial pulse faster
- D. Differ, depending on quality and intensity
Correct Answer: A
Rationale: In a normal healthy individual, the rate of the radial pulse (peripheral pulse) and the heart rate (apical pulse) should be the same. This is because each heartbeat should result in a corresponding pulse felt at the radial artery in the wrist. The pulse is generated by the heart's contraction and the subsequent ejection of blood into the arteries, causing a wave of pressure that can be felt as the pulse. Therefore, in a healthy individual, the radial pulse rate should match the heart rate. If there is a significant difference between the two rates, it may indicate a cardiovascular abnormality or other underlying health condition that warrants further investigation.
What dietary advice should the nurse give to clients with HIV/AIDS?
- A. Encourage the intake of fat soluble vitamins in amounts 2 to 5 times the recommended daily allowance (RDA)
- B. Encourage intake of water soluble vitamins in amounts 2 to 5 times the RDA
- C. Increase the intake of iron and zinc
- D. Decrease the intake of trace elements and antioxidant supplements
Correct Answer: D
Rationale: It is important for clients with HIV/AIDS to maintain a balanced diet that includes a variety of healthy foods to help support their immune system and overall health. While it may be beneficial for them to increase their intake of certain vitamins and minerals, such as vitamin C and zinc, it is generally recommended to get these nutrients from food sources rather than supplements. In fact, there is no evidence to support the routine use of trace elements and antioxidant supplements in individuals with HIV/AIDS. It is always best to consult with a healthcare provider or a dietitian for tailored dietary advice based on individual needs and health status.
The client with epilepsy is taking the prescribed dose of phenytoin (Dilantin) to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/ml. Which of the following symptoms would be expected as a result of this laboratory result?
- A. Nystagmus
- B. No symptoms, because this is normal
- C. Tachycardia therapeutic level
- D. Slurred speech
Correct Answer: A
Rationale: A phenytoin blood level of 35 mcg/ml is considered to be above the therapeutic range (usually 10-20 mcg/ml for phenytoin). At this elevated level, the client is at risk for phenytoin toxicity. Symptoms of phenytoin toxicity include nystagmus (rapid, involuntary eye movements), as well as other symptoms such as confusion, slurred speech, ataxia, and tremors. Tachycardia is not typically associated with phenytoin toxicity. Therefore, the expected symptom in this case would be nystagmus.
You are discussing failure to thrive (FTT) with medical students. You mention that FTT is most often used to describe malnutrition related to environmental or psychosocial causes. An important statement that should be included in your discussion is
- A. FTT is often diagnosed by weight that falls below the 25th percentile for age
- B. a weight crossing one major percentile lines on the growth height should be evaluated for FTT chart over time is considered abnormal
- C. a weight of less than 60 % of the median weight for the height of the child
- D. small subset of the population naturally falls below the 3rd percentile but usually have normal weight for height
Correct Answer: B
Rationale: Crossing percentile lines on a growth chart indicates a significant deviation from the child's previous growth trajectory, which is a key indicator of potential FTT.
Which of the ff. would the nurse explain to the patient is the triad of symptoms associated with Meniere's disease?
- A. Hearing loss, vertigo, and tinnitus
- B. Nausea, vomiting and pain
- C. Nystagmus, headache and vomiting
- D. Nystagmus, vomiting and pain
Correct Answer: A
Rationale: Meniere's disease is a disorder of the inner ear characterized by the triad of symptoms including hearing loss, vertigo (a spinning sensation), and tinnitus (ringing in the ear). These symptoms can occur episodically and may be associated with a feeling of fullness in the affected ear. Other symptoms such as nausea and vomiting may sometimes accompany the episodes of vertigo, but the classic triad of Meniere's disease consists of hearing loss, vertigo, and tinnitus. Nystagmus, headache, and pain are not typically part of the classic presentation of Meniere's disease.