A nurse is caring for a client who reports that he has a headache and vertigo after turning on his furnace for the first time this season.
The nurse suspect which of the following?
Carbon monoxide poisoning
Meniere’s disease
Migraine
Benign paroxysmal positional vertigo.
The Correct Answer is A
Carbon monoxide poisoning.
This is because the client reports having a headache and vertigo after turning on his furnace for the first time this season. These are common symptoms of carbon monoxide poisoning, which can occur when carbon monoxide, a colorless and odorless gas, builds up in the blood due to exposure to combustion fumes.
The furnace may have been a source of carbon monoxide if it was not well vented or maintained.
The other statements are wrong because:
Meniere’s disease is a disorder of the inner ear that causes vertigo, hearing loss, tinnitus and ear fullness. It is not related to carbon monoxide exposure or furnace use.
Migraine is a type of headache that causes throbbing pain, nausea, sensitivity to light and sound, and sometimes visual disturbances. It is not caused by carbon monoxide exposure or furnace use, but by genetic and environmental factors.
Benign paroxysmal positional vertigo (BPPV) is a condition that causes brief episodes of vertigo triggered by changes in head position. It is caused by tiny crystals in the inner ear that become dislodged and stimulate the balance sensors. It is not related to carbon monoxide exposure or furnace use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Swaddling, pacifiers, gentle touch and music therapy are all non-pharmacological interventions that can help soothe a newborn during an assessment.
These methods can provide comfort, security, distraction and stimulation for the newborn.
Choice D is wrong because glucose water is a pharmacological intervention that can be used to reduce pain during procedures such as heel sticks or circumcision.Glucose water should not be given routinely to newborns as it can interfere with breastfeeding and cause electrolyte imbalances.
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Correct Answer is D
Explanation
Based on the Apgar score components provided, the newborn would likely receive the following scores:
- Appearance (color):Pink all over -2 points
- Pulse (heart rate):120 bpm -2 points
- Grimace (reflex irritability):Makes a strong cry -2 points
- Activity (muscle tone):Active movement -2 points
- Respiration:Deep, regular breaths -2 points
Adding these together, the newborn’s Apgar score would be10, which indicates the baby is in excellent condition following delivery.
The Apgar score is a quick assessment method used to evaluate a newborn baby’s health immediately after birth and again 5 minutes later. It was created by Dr. Virginia Apgar in 1952 and is an important tool for healthcare professionals to determine the immediate physical condition of a newborn and the need for any urgent medical care.
Here’s what the Apgar score measures, with each category receiving a score from 0 to 2:
- Appearance (color):Checks the baby’s skin tone
- Pulse (heart rate):Measures the heart rate
- Grimace (reflex irritability):Assesses the reflex response
- Activity (muscle tone):Evaluates muscle tone and movement
- Respiration:Observes the breathing effort and regularity
The significance of the Apgar score lies in its ability to provide a standardized and rapid assessment of a newborn’s vital signs and immediate health. It helps to quickly identify babies who are struggling and may need additional medical attention.However, it’s important to note that the Apgar score is not designed to predict long-term health outcomes or neurological development.It’s one of many assessments used to understand a baby’s condition at birth.
Here’s a table that outlines the Apgar score criteria and the points assigned for each:
Table
Criteria |
0 Points |
1 Point |
2 Points |
Appearance (Color) |
Blue or pale all over |
Body pink, extremities blue |
Pink all over |
Pulse (Heart Rate) |
Absent |
Less than 100 bpm |
100 bpm or more |
Grimace Response |
No response to stimulation |
Grimace or weak cry |
Strong cry, pulls away |
Activity (Muscle Tone) |
Limp |
Some flexion of extremities |
Active motion |
Respiration |
Absent |
Slow or irregular breathing |
Good, strong cry |
The Apgar score is calculated at 1 minute and 5 minutes after birth. Each of the five criteria is scored between 0 and 2, with a maximum total score of 10. This scoring system helps medical professionals quickly assess the newborn’s general condition and determine if any immediate medical intervention is needed. A score of 7 to 10 is considered normal, 4 to 6 fairly low, and 3 and below critically low.
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