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 B
Explanation
Flexion in different positions.The New Ballard Scale is a scale that estimates the gestational age of a newborn infant based on physical and neuromuscular characteristics.Flexion in different positions is one of the six neuromuscular signs that are assessed using the scale.The other neuromuscular signs are square window, arm recoil, popliteal angle, scarf sign, and heel to ear.
The other statements are wrong because:
Skin thickness and presence of lanugo are physical signs, not neuromuscular signs.They are also assessed using the New Ballard Scale, along with plantar surface, breast, eye/ear, and genitals.
Creases on the bottom of feet are part of the plantar surface assessment, which is a physical sign, not a neuromuscular sign.
Scrotum development is part of the genital assessment, which is a physical sign, not a neuromuscular sign.
The New Ballard Scale can be used up to 4 days after birth, but usually within the first 24 hours.The scale is accurate only within plus or minus 2 weeks.The total score determines the gestational maturity in weeks.
Correct Answer is A
Explanation
Normal finding.
The anterior fontanelle is the soft spot on the top of an infant’s head that allows for brain growth and skull expansion.
It normally feels soft and flat when the infant is lying down, and may bulge slightly when the infant is sitting up or crying due to increased blood flow and pressure.
This is not a sign of any problem and should be documented as a normal finding.
Dehydration is wrong because dehydration would cause the fontanelle to feel sunken or depressed, not elevated. Dehydration can also cause other signs such as dry mouth, decreased urine output, and lethargy.
Increased intracranial pressure is wrong because increased intracranial pressure would cause the fontanelle to feel tense or bulging at all times, not only when sitting up or crying. Increased intracranial pressure can also cause other signs such as vomiting, irritability, seizures, and altered level of consciousness.
Infection is wrong because infection would cause the fontanelle to feel warm or tender, not elevated. Infection can also cause other signs such as fever, rash, poor feeding, and fussiness.
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