Nokea
Why should a 30-year-old Caucasian woman who works the night shift take Vitamin D supplements?
- A. It's a standard part of the overall nutritional treatment for the prevention of osteomalacia.
- B. It helps your intestines absorb calcium, which is important for bone formation.
- C. It stimulates skin cells to produce calcium, which is then released into the bloodstream to be used for bone formation.
- D. Vitamin D supplements should not be taken by someone of your age.
Correct Answer: B
Rationale: The correct answer is B: 'It helps your intestines absorb calcium, which is important for bone formation.' Vitamin D plays a crucial role in aiding the absorption of calcium from the intestines into the bloodstream, which is essential for bone health and formation. Choice A is incorrect because it does not specifically address the role of Vitamin D in calcium absorption. Choice C is incorrect as Vitamin D does not stimulate skin cells to produce calcium; rather, it helps regulate calcium levels in the body. Choice D is incorrect as age alone is not a contraindication for Vitamin D supplementation; the need for supplementation is based on individual health status and risk factors.
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The nurse is planning discharge instructions for the mother of a child following orchiopexy, which was performed on an outpatient basis. Which is a priority in the plan of care?
- A. Wound care
- B. Pain control measures
- C. Measurement of intake
- D. Cold and heat applications
Correct Answer: A
Rationale: Following orchiopexy, the priority in the plan of care for the child's mother is wound care. The most common complications associated with orchiopexy are bleeding and infection. Discharge instructions should focus on demonstrating wound cleansing and dressing, and teaching parents to recognize signs of infection like redness, warmth, swelling, or discharge. It is crucial to prevent movement of the testicles and avoid contamination of the suture line. While analgesics may be prescribed, pain control measures are not the priority among the options presented. Measurement of intake is not essential as the child is likely to resume normal eating habits. Cold and heat applications are not typical prescribed treatments for post-orchiopexy care.
Which of the following signs is NOT indicative of increased intracranial pressure?
- A. Decreased level of consciousness
- B. Projectile vomiting
- C. Sluggish pupil dilation
- D. Increased heart rate
Correct Answer: D
Rationale: Increased intracranial pressure can lead to serious complications if not promptly addressed. Common signs of increased intracranial pressure include decreased level of consciousness, sluggish pupil dilation, abnormal respirations, and projectile vomiting. However, an increased heart rate is not a typical sign associated with increased intracranial pressure. It is important for healthcare providers to recognize these signs early to prevent severe consequences such as brain herniation.
Mr. C is brought to the hospital with severe burns over 45% of his body. His heart rate is 124 bpm and thready, BP 84/46, respirations 24/minute and shallow. He is apprehensive and restless. Which of the following types of shock is Mr. C at highest risk for?
- A. Septic shock
- B. Hypovolemic shock
- C. Neurogenic shock
- D. Cardiogenic shock
Correct Answer: B
Rationale: Mr. C, who has severe burns over 45% of his body, is at highest risk for hypovolemic shock. Burns lead to a loss of plasma volume, reducing the circulating fluid volume and impairing perfusion to vital organs and extremities. In this scenario, the signs of shock, such as increased heart rate, low blood pressure, shallow respirations, and restlessness, indicate a state of hypovolemic shock due to significant fluid loss. Septic shock (choice A) is primarily caused by severe infections, neurogenic shock (choice C) results from spinal cord injuries, and cardiogenic shock (choice D) stems from heart failure. However, in this case, the presentation aligns most closely with hypovolemic shock due to the extensive burn injury and its effects on fluid volume and perfusion.
The nurse reviews the record of a child who is suspected to have glomerulonephritis. Which statement by the child's parent should the nurse expect that is associated with this diagnosis?
- A. His pediatrician said his kidneys are working well.''
- B. I noticed his urine was the color of cola lately.''
- C. I'm so glad they didn't find any protein in his urine.''
- D. The nurse who admitted my child said his blood pressure was low.''
Correct Answer: B
Rationale: Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria, resulting in dark, smoky, cola-colored, or brown-colored urine, is a classic symptom of glomerulonephritis. Blood urea nitrogen levels and serum creatinine levels may be elevated, indicating that kidney function is compromised. A mild to moderate elevation in protein in the urine is associated with glomerulonephritis. Hypertension is also common because of fluid volume overload secondary to the kidneys not working properly. Therefore, the parent's statement about noticing cola-colored urine aligns with the expected symptom in glomerulonephritis. The other options are less indicative of glomerulonephritis: choice A indicates normal kidney function, choice C mentions absence of protein in the urine (which is not expected in glomerulonephritis), and choice D talks about low blood pressure (hypertension is more common in glomerulonephritis).
A patient asks the nurse why they must have a heparin injection. What is the nurse's best response?
- A. Heparin will dissolve clots that you have.
- B. Heparin will reduce the platelets that make your blood clot.
- C. Heparin will work better than warfarin.
- D. Heparin will prevent new clots from developing.
Correct Answer: D
Rationale: The correct answer is D: 'Heparin will prevent new clots from developing.' Heparin is an anticoagulant medication that helps prevent the formation of new blood clots. It does not dissolve existing clots (choice A), reduce platelets (choice B), or necessarily work 'better' than warfarin (choice C) but rather functions differently. The primary action of heparin is to prevent the development of new clots, especially in conditions where clot formation is a concern.