Nokea
Which of the following terms refers to soft-tissue injury caused by blunt force?
- A. contusion
- B. strain
- C. sprain
- D. dislocation
Correct Answer: A
Rationale: A contusion is a soft-tissue injury from blunt force, causing swelling and discoloration without breaking the skin. Strains and sprains involve ligaments or muscles, and dislocation affects joints. Physiological Adaptation
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Additional assessment on Antoinette include
dehydration and menorrhagia.
- A. buffalo hump and hypertension.
- B. pitting edema and frequent colds.
- C. migraine headache and dymennorhea.
Correct Answer: B
Rationale: Cushing's syndrome results from excess adrenocortical activity. Signs include slow wound healing, buffalo hump, hirsutism, weight gain, hypertension, acne, moon face, thin arms and legs, and behavioral changes.
A nurse is caring for a patient with diabetes mellitus who is experiencing hyperglycemia. Which of the following interventions should the nurse implement? (Select all that apply)
- A. Administer insulin as prescribed
- B. Provide sugar-free fluids
- C. Encourage carbohydrate-rich snacks
- D. Monitor blood glucose levels regularly
- E. Assess for signs of diabetic ketoacidosis (DKA)
Correct Answer: A,B,D,E
Rationale: Insulin corrects hyperglycemia, sugar-free fluids prevent dehydration, monitoring tracks progress, and DKA assessment detects complications. Carbohydrate snacks worsen hyperglycemia.
While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?
- A. Jaundice evident at 26 hours
- B. Hematocrit of 55%
- C. Serum bilirubin of 12 mg
- D. Positive Coombs' test
Correct Answer: C
Rationale: The elevated bilirubin is in the range that requires immediate intervention, such as phototherapy. At a serum bilirubin of 12 mg, the neonate is at risk for the development of kernicterus, or bilirubin encephalopathy. The provider determines the therapy appropriate after reviewing all laboratory findings.
The patient is taking antidepressant drug, Elavil. The spouse of the patient complains that the dosage of the drug needs to be increased because no improvement is noted. The patient has been taking the drug for the last 3 days and no improvement is noted.
The most appropriate nursing response would be:
- A. I will inform the physician about your concern.
- B. It may take 3 to 4 weeks for the drug to work.
- C. The drug should work right away.
- D. Possible drug resistant has developed.
Correct Answer: B
Rationale: Elavil, a tricyclic antidepressant, typically takes 3–4 weeks to show therapeutic effects.
A newborn is to receive phototherapy for hyperbilirubinemia. Which nursing action is essential?
- A. Keep the infant NPO for two hours before the treatment.
- B. Ask the mother to stay away from the infant during the treatment.
- C. Monitor the client's pulse rate very carefully.
- D. Cover the baby's eyes during the treatment.
Correct Answer: D
Rationale: Covering the eyes protects the newborn's retinas from phototherapy light, a critical safety measure.