Nokea
Which statement best describes the clinical manifestations of the preterm newborn?
- A. Head is proportionately small in relation to the body.
- B. Sucking reflex is absent, weak, or ineffectual.
- C. Thermostability is well established.
- D. Extremities remain in attitude of flexion.
Correct Answer: D
Rationale: The statement that best describes the clinical manifestations of the preterm newborn is that the extremities remain in an attitude of flexion. This characteristic is known as the "fetal position" and is commonly observed in preterm infants due to their premature musculoskeletal development. The flexed position of the extremities is a result of the baby's position in the uterus and is a normal finding for preterm newborns. Other clinical manifestations of preterm newborns may include a disproportionately large head in relation to the body, an immature or weak sucking reflex, and decreased thermostability due to their underdeveloped thermoregulatory systems.
You may also like to solve these questions
Which of the following diets would the nurse include in the plan of care for a person with AIDS?
- A. A high-protein, high-calorie diet divided into six small meals.
- B. A low-fat, soft diet divided into 8 small meals.
- C. A high-carbohydrate, fat-restricted diet divided into 4 meals.
- D. A high-fat, high-calorie diet divided into 3 meals.
Correct Answer: A
Rationale: People with AIDS often experience weight loss and malnutrition due to the disease's impact on the immune system. A high-protein, high-calorie diet can help support the immune system and maintain or improve weight. Dividing the meals into six servings can help with better absorption of nutrients and provide a steady source of energy throughout the day. This type of diet can also help manage symptoms and side effects of the disease and its treatments, such as maintaining muscle mass, managing nausea, and supporting overall health.
In planning safe care for the older adult, which of the ff. conditions does the nurse recognize would not cause visual problems?
- A. Glaucoma
- B. Macular degeneration
- C. Cataracts
- D. Arcus senilis
Correct Answer: D
Rationale: Arcus senilis is a condition characterized by a white or gray ring forming around the cornea and does not typically cause visual problems. It is a common and benign condition often seen in older adults. On the other hand, glaucoma, macular degeneration, and cataracts are all eye conditions that can significantly affect vision and lead to visual impairments in older adults. Therefore, in planning safe care for the older adult, the nurse should recognize that Arcus senilis would not cause visual problems unlike the other conditions mentioned.
A female child, age 6, is brought to the health clinic for a routine checkup. To assess the child's vision, the nurse should ask:
- A. "Do you have any problems seeing different colors?"
- B. "Do you have trouble seeing at night?"
- C. "Do you have problems with glare?"
- D. "How are you doing in school?"
Correct Answer: A
Rationale: Asking the child if they have any problems seeing different colors is a suitable way to assess their vision during a routine checkup. Issues with colors can indicate potential color blindness or other vision problems. Asking about night vision (choice B) or glare (choice C) might be more relevant in specific situations or with older patients. Inquiring about their performance in school (choice D) could provide information related to vision but is not as direct and specific as asking about color vision.
The nurse is preparing to administer a unit of blood to a client's who's anemic. After its removal from the refrigerator, the blood should be administered within:
- A. 1 hour
- B. 4 hours
- C. 2 hours
- D. 6 hours
Correct Answer: B
Rationale: After blood is removed from the refrigerator, it should be administered within 4 hours. Blood should be stored in a controlled temperature environment to prevent bacterial growth and to maintain its effectiveness. In order to minimize the risk of bacterial contamination, it is important for the nurse to adhere to the recommended time frame for administering blood products. Administering the blood within 4 hours helps ensure its safety and effectiveness for the client.
How can the nurse help monitor effectiveness of therapy for the patient with a pneumothorax and chest-drainage system?
- A. Palpate for crepitus
- B. Document color and amount of sputum
- C. Auscultate lung sounds
- D. Monitor suction level
Correct Answer: C
Rationale: The nurse can help monitor the effectiveness of therapy for a patient with a pneumothorax and chest drainage system by auscultating lung sounds. Auscultation can provide information about the air movement within the lungs and any changes in lung sounds, such as decreased or absent breath sounds on the affected side, which may indicate improvement or deterioration in the patient's condition. By regularly assessing lung sounds, the nurse can track the progress of the therapy and make informed decisions about the patient's care and treatment plan. Palpating for crepitus, documenting sputum characteristics, and monitoring suction levels are important aspects of care but are not specifically focused on assessing the effectiveness of therapy for a pneumothorax.