The nurse is assessing a newborn while the new parents watch. The nurse uses an ophthalmoscope to examine the back of the eye (the retina) and notes a positive red reflex. The nurse would explain to the parents that the red reflex indicates:
1. The absence of congenital cataracts.
2. The presence of intraocular hemorrhage.
3. The optic nerve has been traumatized during delivery.
4. Presence of amblyopia.
1
Rationale 1: The light of the ophthalmoscope is reflecting off the retina producing the red reflex. This indicates there is nothing preventing the transfer of light.
Rationale 2: The red reflex is a normal finding.
Rationale 3: The optic nerve is behind the retina and not visible.
Rationale 4: Amblyopia cannot be diagnosed at this time and is not evaluated with an ophthalmoscope.
Global Rationale:
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A dispute arises between an RN staff member and an LPN over a patient issue. The tension between the two begins to affect other staff members, who are drawn into the conflict; eventually, the team becomes polarized toward either the RN or the LPN
This situation might have been prevented through: a. Expediency in responding to the initial dispute, once it became apparent that it could not be resolved by the two parties themselves. b. Asking other staff members what the real issues were in the dispute between the RN and the LPN. c. Reassigning one of the parties to another unit when it became apparent that the two individuals could not resolve the dispute themselves. d. Calling a staff meeting at the onset of the dispute to allow the team and the RN and LPN to discuss the initial dispute.
Diarrhea associated with lactose intolerance can result in nutritional deficiencies and electrolyte imbalance. A child with lactose intolerance may need calcium and vitamin D supplements to meet their requirements for:
1. Adequate blood clotting. 2. Bone mineralization and growth. 3. Fat stores in the buttocks and breasts. 4. Muscle tissue.
Following an open loop resection and fulguration of the bladder, a patient is unable to void. Which nursing action should be implemented first?
a. Insert a straight catheter and drain the bladder. b. Assist the patient to take a 15-minute sitz bath. c. Encourage the patient to drink several glasses of water. d. Teach the patient how to do isometric perineal exercises.
A patient has a glomerular filtration rate of 20 mL/min. For which stage of renal failure should the nurse plan care for this patient?
a. Mild b. Slight c. Severe d. Moderate