Nokea
Which of the following would indicate that the patient has a normal corneal light reflex?
- A. The eye focuses the image in the center of the pupil.
- B. The eyes converge to focus on the light.
- C. Constriction of both pupils occurs in response to bright light.
- D. Light is reflected at the same spot in both eyes.
Correct Answer: D
Rationale: A normal corneal light reflex, also known as the Hirschberg test, is assessed by shining a light into the patient's eyes and observing the reflection of the light on the corneas. In a normal response, the light should be reflected at the same spot in both eyes. If the light is off-center in one eye compared to the other, it could indicate a deviation in the alignment of the eyes, known as strabismus. Therefore, choice D, "Light is reflected at the same spot in both eyes," is the correct indicator of a normal corneal light reflex.
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A patient is diagnosed with Hashimoto's thyroiditis and asks what causes it. The nurse would respond that the destruction of the thyroid in this condition is due to which of the following?
- A. Antigen-antibody complexes
- B. Viral infection
- C. Autoantibodies
- D. Bacterial infection
Correct Answer: C
Rationale: Hashimoto's thyroiditis is an autoimmune disorder where the body's immune system mistakenly attacks the thyroid gland. In this condition, the immune system produces autoantibodies that target proteins in the thyroid tissue, causing inflammation and destruction of the thyroid gland over time. This process leads to hypothyroidism, as the damaged thyroid is no longer able to produce sufficient thyroid hormones. Autoantibodies are a hallmark of Hashimoto's thyroiditis and are responsible for the destruction of the thyroid gland in this condition.
Mr. Sison had an above the knee amputation (AKA). He is taught to use crutches while prosthesis is being adjusted. The nurse instruct the client to support her weight primarily on which areas?
- A. axilla
- B. upper arms
- C. elbows
- D. hands
Correct Answer: C
Rationale: When using crutches after an above the knee amputation, it is important for the client to support their weight primarily on their elbows. Placing the weight on the elbows helps to prevent pressure on the axilla (armpit area), which can lead to nerve damage and discomfort. Supporting weight on the elbows also provides better stability and control while using crutches, allowing the client to move more safely and comfortably. Additionally, distributing the weight onto the elbows helps to avoid potential strain and injury to the hands or upper arms.
A patient is admitted who has had severe vomiting for 24 hours. She states that she is exhausted and weak. The results of an admitting ECG show flat T waves and ST segment depression. Choose the most likely potassium (K ) value for this patient.
- A. 4.0mEq/L
- B. 2.0mEq/L
- C. 8.0mEq/L
- D. 2.6mEq/L
Correct Answer: B
Rationale: The patient is displaying signs of hypokalemia (low potassium levels) due to severe vomiting. Symptoms of hypokalemia can include weakness, fatigue, and ECG changes such as flat T waves and ST segment depression. The potassium level that is most likely associated with these symptoms is 2.0mEq/L. Severe vomiting can lead to significant loss of potassium from the body, causing these abnormalities. It is important to address and correct the potassium imbalance to prevent further complications.
A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?
- A. "Keep the stoma uncovered."
- B. "Keep the stoma dry."
- C. "Have a family member perform stoma care initially until you get used to the procedure."
- D. "Keep the stoma moist."
Correct Answer: B
Rationale: It is important to keep the stoma dry to prevent infection and skin irritation. Excess moisture can lead to skin breakdown around the stoma site, increasing the risk of infection. It is recommended to keep the stoma clean and dry to promote healing and prevent complications.
The first permanent tooth to erupt is
- A. central incisor at 6 years
- B. molar at 6 years
- C. premolar lower canine at 6-7 years
- D. upper canine at 6-7 years
Correct Answer: B
Rationale: The first molar typically erupts at 6 years.