Nokea
A child is seen in the emergency department for scarlet fever. Which of the following descriptions of scarlet fever is not correct?
- A. Scarlet fever is caused by infection with group A Streptococcus bacteria.
- B. "Strawberry tongue"? is a characteristic sign.
- C. Petechiae occur on the soft palate.
- D. The pharynx is red and swollen.
Correct Answer: C
Rationale: Petechiae on the soft palate are not a typical finding in scarlet fever. Scarlet fever is caused by group A Streptococcus bacteria, often presenting with a strawberry tongue, red and swollen pharynx, and a sandpaper-like rash. The presence of petechiae on the soft palate is more commonly associated with conditions like rubella rather than scarlet fever. Therefore, this description is not correct in the context of scarlet fever.
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A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included in the nursing care plan?
- A. Monitor for fever every 4 hours.
- B. Require visitors to wear respiratory masks and protective clothing.
- C. Consider transfusion of packed red blood cells.
- D. Check for signs of bleeding, including examination of urine and stool for blood.
Correct Answer: D
Rationale: A platelet count of 25,000/microliter indicates severe thrombocytopenia, which increases the risk of bleeding. It is crucial to initiate bleeding precautions, including regularly checking for signs of bleeding such as examining urine and stool for blood. Monitoring for fever every 4 hours (Choice A) should be included for neutropenic precautions, not specifically related to platelet count. Requiring visitors to wear respiratory masks and protective clothing (Choice B) is more relevant for patients with airborne precautions. Considering transfusion of packed red blood cells (Choice C) is not indicated for low platelet count but is more appropriate for managing anemia or low hemoglobin levels.
A nurse is caring for an infant who has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present?
- A. Slow pulse rate
- B. Weight gain
- C. Decreased systolic pressure
- D. Irregular WBC lab values
Correct Answer: B
Rationale: Weight gain due to fluid accumulation is associated with heart failure and congenital heart defects. When the heart is unable to circulate blood normally, the kidneys receive less blood, leading to reduced fluid filtration into the urine. The excess fluid accumulates in various body parts such as the lungs, liver, eyes, and sometimes in the legs. Slow pulse rate (Choice A) is less likely as infants with heart failure typically present with tachycardia due to the body compensating for decreased cardiac output. Decreased systolic pressure (Choice C) is also less likely as heart failure typically leads to increased blood pressure as the body tries to maintain adequate perfusion. Irregular white blood cell (WBC) values (Choice D) are not directly associated with congenital heart defects unless there is an underlying infection or inflammatory process.
An 85-year-old client is diagnosed with hypernatremia due to lack of fluid intake and dehydration. The nurse knows that symptoms of hypernatremia include:
- A. Lack of thirst
- B. Pale skin
- C. Hypertension
- D. Swollen tongue
Correct Answer: D
Rationale: Hypernatremia among elderly clients can result from dehydration and insufficient fluid intake, leading to sodium levels above 145 mEq/L. Common symptoms of hypernatremia include mental status changes, a thick or swollen tongue, excessive thirst, and flushed skin. Choice A, 'Lack of thirst,' is incorrect as hypernatremia typically presents with excessive thirst. Choice B, 'Pale skin,' is not a typical symptom of hypernatremia. Choice C, 'Hypertension,' is not a direct symptom of hypernatremia and is more commonly associated with other conditions like hypertension itself.
A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage?
- A. The tumor is less than 3 cm in size and requires no chemotherapy.
- B. The tumor did not extend beyond the kidney and was completely resected.
- C. The tumor extended beyond the kidney but was completely resected.
- D. The tumor has spread into the abdominal cavity and cannot be resected.
Correct Answer: C
Rationale: In Wilms tumor staging, stage II indicates that the tumor extends beyond the kidney but is completely resected. This means that the tumor has spread beyond the kidney but has been successfully removed. Choices A and B are incorrect because a tumor less than 3 cm in size and a tumor that did not extend beyond the kidney do not align with the characteristics of stage II Wilms tumor. Choice D is also incorrect as it describes a more advanced stage where the tumor has spread into the abdominal cavity and cannot be completely resected. Therefore, the correct answer is C, as it accurately reflects the characteristics of a stage II Wilms tumor.
You are responsible for reviewing the nursing unit's refrigerator. Which of the following drugs, if found inside the fridge, should be removed?
- A. Nadolol (Corgard)
- B. Opened (in-use) Humulin N injection
- C. Urokinase (Kinlytic)
- D. Epoetin alfa IV (Epogen)
Correct Answer: A
Rationale: Nadolol (Corgard) should be removed if found inside the fridge because it is supposed to be stored at room temperature between 59 to 86 ºF (15 and 30 ºC) away from heat, moisture, and light. Storing it in the refrigerator can alter its effectiveness and stability.
Option B, the opened Humulin N injection, should not be stored in the refrigerator as it is an in-use product and can remain at room temperature for a certain period as per manufacturer guidelines. Option C, Urokinase (Kinlytic), and Option D, Epoetin alfa IV (Epogen), do not require refrigeration and can be stored at room temperature. Therefore, Nadolol (Corgard) is the drug that should be removed from the fridge.