Sunday, 25 October 2020

Q. A nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones?

A. 7 weeks' gestation

B. 11 weeks' gestation

C. 17 weeks' gestation

D. 21 weeks' gestation

Correct Answer: B

Reason: Using Doppler ultrasound, fetal heart tones may be heard as early as the 11th week of pregnancy. Using a stethoscope, fetal heart tones may be heard between 17 and 20 weeks' gestation.

Friday, 23 October 2020

Question Of The Day, Mood, Adjustment, and Dementia Disorders
Q. Family members of a client with bipolar disorder tell a nurse that they are concerned that the client is becoming manic. The nurse knows that the manic phase is marked by:

A. flight of ideas and inflated self-esteem.

B. increased sleep and greater distractibility.

C. decreased self-esteem and increased physical restlessness.

D. obsession with following rules and maintaining order.

Correct Answer: A

Reason: The manic phase of bipolar disorder is characterized by recurrent episodes of a persistently euphoric and expansive or irritable mood. This phase is diagnosed if the client experiences four of the following signs and symptoms for at least 1 week: flight of ideas; inflated self-esteem; unusual talkativeness; increased social, occupational, or sexual activity; physical restlessness; a decreased need for sleep; increased distractibility; and excessive involvement in activities with a high potential for painful but unrecognized consequences. Obsession with following rules and maintaining order characterizes obsessive-compulsive disorder.

Tuesday, 20 October 2020

Question Of The Day, Toddler
Q. When performing a physical assessment on an 18-month-old child, which of the following would be best?

A. Have a parent hold the toddler.

B. Assess the ears and mouth first.

C. Carry out the assessment from head to toe.

D. Assess motor function by having the child run and walk.

Correct Answer: A

Reason: The best strategy for assessing a toddler is to have the parent hold the toddler. Doing so is comforting to the toddler. Assessment should begin with noninvasive assessments first while the child is quiet. Typically these include assessments of the cardiac and respiratory systems. The ears and throat are typically examined last. Using a head-to-toe approach is more appropriate for an older child. For a toddler, assessment should begin with noninvasive assessments first while the child is quiet. Having a toddler run and be active may make it difficult to settle the child down after the physical exertion.

Friday, 16 October 2020

Q. The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate?

A. Have the client wear eyeglasses at all times.

B. Lightly tape the eyelid shut.

C. Instill artificial tears once every shift.

D. Clean the eyelid with a washcloth every shift.

Correct Answer: B

Reason: When the blink reflex is absent or the eyes do not close completely, the cornea may become dry and irritated. Corneal abrasion can occur. Taping the eye closed will prevent injury. Having the client wear eyeglasses or cleaning the eyelid will not protect the cornea from dryness or irritation. Artificial tears instilled once per shift are not frequent enough for preventing dryness.

Tuesday, 13 October 2020

Question Of The Day, Neurosensory Disorders
Q. A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed?

A. Immediately go the client's room and assess vital signs, administer oxygen at 2 L/minute, and notify the physician.

B. Ask the nursing assistant to notify the physician of the low pulse oximetry level.

C. Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.

D. Complete the assessment of the new client before attending to the client who underwent laminectomy.

Correct Answer: C

Reason: Because it's important to get more information about the client with a decreased pulse oximetry level, the nurse should ask the LPN to obtain vital signs and administer oxygen as ordered. The nurse must attend to the newly admitted client without delaying treatment to the client who is already in her care. The nurse can effectively do this by delegating tasks to an appropriate health team member such as an LPN. The nurse doesn't need to immediately attend to the client with a decreased pulse oximetry level; she may wait until she completes the assessment of the newly admitted client. The physician doesn't need to be notified at this time because an order for oxygen administration is already on record.

Friday, 9 October 2020

Question Of The Day, Oncologic Disorders
Q. A young man with early-stage testicular cancer is scheduled for a unilateral orchiectomy. The client confides to the nurse that he is concerned about what effects the surgery will have on his sexual performance. Which of the following responses by the nurse provides accurate information about sexual performance after an orchiectomy?

A. "Most impotence resolves in a couple of months."

B. "You could have early ejaculation with this type of surgery."

C. "We will refer you to a sex therapist because you will probably notice erectile dysfunction."

D. "Because your surgery does not involve other organs or tissues, you'll likely not notice much change in your sexual performance."

Correct Answer: D

Reason: Although there may not be a big change in sexual function with a unilateral orchiectomy, the loss of a gonad and testosterone may result in decreased libido and sterility. Sperm banking may be an option worth exploring if the number and motility of the sperm are adequate. Remember, the population most affected by testicular cancer is generally young men ages 15 to 34, and in this crucial stage of life, sexual anxieties may be a large concern.

Thursday, 8 October 2020

Q. Before discharge, which instruction should a nurse give to a client receiving digoxin (Lanoxin)?

A. "Take an extra dose of digoxin if you miss one dose."

B. "Call the physician if your heart rate is above 90 beats/minute."

C. "Call the physician if your pulse drops below 80 beats/minute."

D. "Take digoxin with meals."

Correct Answer: B

Reason: The nurse should instruct the client to notify the physician if his heart rate is greater than 90 beats/minute because cardiac arrhythmias may occur with digoxin toxicity. To prevent toxicity, the nurse should instruct the client never to take an extra dose of digoxin if he misses a dose. The nurse should show the client how to take his pulse and tell him to call the physician if his pulse rate drops below 60 beats/minute — not 80 beats/minute, which is a normal pulse rate and doesn't warrant action. The client shouldn't take digoxin with meals; doing so slows the absorption rate.

Wednesday, 7 October 2020

Q. The neonate of a client with type 1 diabetes is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is:

A. peripheral acrocyanosis.

B. bradycardia.

C. lethargy.

D. jaundice.

Correct Answer: C

Reason: Lethargy in the neonate may be seen with hypoglycemia because of a lack of glucose in the nerve cells. Peripheral acrocyanosis is normal in the neonate because of immature capillary function. Tachycardia — not bradycardia — is seen with hypoglycemia. Jaundice isn't a sign of hypoglycemia.

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