Nokea
The school nurse suspects a testicular torsion in a young adolescent student. What action should the nurse take?
- A. Place a warm moist pack on the scrotal area.
- B. Instruct the adolescent to lie down and elevate the legs.
- C. Refer the adolescent for immediate medical evaluation.
- D. Suggest that the adolescent wear a scrotum-protecting guard.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse is preparing to administer an intramuscular injection to a toddler-age client. Which is the most appropriate statement by the nurse prior to this procedure?
- A. "We will give you your shot when your mommy comes back."
- B. "I will wipe your skin with a magic wipe and then hold the needle like this and say one, two, three, go and give you your shot. Are you ready?"
- C. "It is all right to cry. After we are done, you can go to the box and pick out your favorite sticker."
- D. "This is a magic sword that will give you your medicine and make you all better."
Correct Answer: C
Rationale: The correct answer is C because it acknowledges the child's feelings, provides clear instructions, and offers comfort and rewards to help the child cope with the procedure. Choice A is not appropriate as it may create anxiety about the injection. Choice B uses the term 'magic,' which may confuse the child and lead to fear. Choice D introduces a fantasy element that may not be beneficial in preparing the child for the injection.
The parents of a child with acute postinfectious glomerulonephritis (APIGN) ask how they will know that the condition is improving. How should the nurse respond?
- A. Your child's urine output will increase, and the urine will become less brown in color.
- B. Your child will rest more comfortably.
- C. Your child's appetite will decrease.
- D. Your child's laboratory test values will show increased BUN.
Correct Answer: A
Rationale: Improvement in APIGN is indicated by an increase in urine output and a change in urine color from brown (due to hematuria) to a more normal appearance. This reflects a reduction in glomerular inflammation and improved kidney function. Choice B is incorrect because resting more comfortably is not a direct indicator of kidney function improvement. Choice C is incorrect because a decrease in appetite is not typically associated with improvement in APIGN. Choice D is incorrect because an increased BUN value would suggest worsening kidney function rather than improvement.
What is the most critical physiologic change required of newborns at birth?
- A. Transition from fetal to neonatal breathing
- B. Body temperature maintenance
- C. Stabilization of fluid and electrolytes
- D. Closure of fetal shunts in the heart
Correct Answer: A
Rationale: The correct answer is A: Transition from fetal to neonatal breathing. The onset of breathing is the most immediate and critical physiologic change required for the transition to extrauterine life. Factors that interfere with this normal transition increase fetal asphyxia, which is a condition of hypoxemia, hypercapnia, and acidosis. While body temperature maintenance, stabilization of fluid and electrolytes, and closure of fetal shunts in the heart are crucial changes in the transition to extrauterine life, breathing and the exchange of oxygen for carbon dioxide must take precedence as they are essential for newborn survival.
What is a primary consideration for complications when planning nursing care for an infant with Meconium aspiration syndrome?
- A. Hypoglycemia
- B. Bowel obstruction
- C. Airway obstruction
- D. Carbon dioxide retention
Correct Answer: C
Rationale: The correct answer is C: Airway obstruction. When planning nursing care for an infant with Meconium aspiration syndrome, a primary consideration for complications is the potential of airway obstruction. After the passage of meconium into the amniotic fluid, the infant may inhale or swallow the fluid, leading to meconium aspiration into the lower airways and causing a partial airway obstruction. This can result in respiratory distress and hypoxemia. Hypoglycemia (choice A) is a metabolic condition unrelated to meconium aspiration. Bowel obstruction (choice B) with meconium may indicate other conditions like cystic fibrosis or Hirschsprung disease, not directly related to meconium aspiration syndrome. Carbon dioxide retention (choice D) is not a primary consideration in meconium aspiration syndrome; instead, the focus is on addressing the airway obstruction and potential respiratory compromise.
What is a priority intervention for an infant with a temporary colostomy for Hirschsprung disease?
- A. Teaching how to irrigate the colostomy
- B. Protecting the skin around the colostomy
- C. Discussing the implications of a colostomy during puberty
- D. Using simple, straightforward language to prepare the child
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.