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Why should the nurse closely monitor older adults when they are receiving IV therapy? Choose all that apply
- A. Because their defense mechanisms are less efficient
- B. Because they are prone to fluid overload
- C. Because they are prone to reduced renal efficiency
- D. Because they have inadequate intake of dietary fiber
Correct Answer: E
Rationale: Older adults should be closely monitored when receiving IV therapy because their defense mechanisms are less efficient (A) as they age, making them more susceptible to infections and complications from invasive procedures like IV therapy. Additionally, older adults are prone to reduced renal efficiency (C), which can affect their ability to excrete excess fluids and electrolytes properly. Monitoring for signs of fluid overload and renal impairment is crucial in this population to prevent adverse outcomes related to IV therapy.
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Which of the ff. nursing interventions will help prevent complications in the patient with Bell's Palsy?
- A. Megavitamin therapy
- B. Application of ice to the affected area
- C. Elastic bandages
- D. Lubricating eye drops
Correct Answer: D
Rationale: Bell's Palsy is a condition that affects the facial nerve, leading to weakness or paralysis of the facial muscles. One common complication of Bell's Palsy is the inability to fully close the affected eye, which can result in corneal exposure and dryness. Lubricating eye drops help prevent dryness and protect the cornea from damage due to inadequate eye closure. Using lubricating eye drops regularly can help maintain the eye's moisture and prevent potential complications such as corneal abrasions and infections, which are common in patients with Bell's Palsy. Megavitamin therapy, application of ice, and elastic bandages are not typically indicated for preventing complications in patients with Bell's Palsy.
Which is the best position for an 8-year-old who has returned after an appendectomy for a ruptured appendix?
- A. Right side-lying.
- B. Semi-Fowler.
- C. Prone.
- D. Left side-lying.
Correct Answer: A
Rationale: Right side-lying promotes drainage of the peritoneal cavity and enhances comfort after surgery.
Clinical manifestations of failure to thrive caused by behavioral problems resulting in inadequate intake of calories include:
- A. avoidance of eye contact.
- B. an associated malabsorption defect.
- C. weight that falls below the 15th percentile.
- D. normal achievement of developmental landmarks.
Correct Answer: C
Rationale: Clinical manifestations of failure to thrive caused by behavioral problems resulting in inadequate intake of calories may include weight that falls below the 15th percentile on growth charts. Weight falling below the 15th percentile may indicate poor nutrition intake leading to inadequate growth and development. Other signs such as avoidance of eye contact, an associated malabsorption defect, and normal achievement of developmental landmarks may not be specific indicators of failure to thrive due to behavioral problems with inadequate calorie intake.
A worried mother of a 4-year-old boy describing attacks of inconsolable crying episodes. The MOST appropriate action is
- A. reassures her that this is a normal phenomenon of temper tantrum
- B. seek more history regarding other skills and developmental domains
- C. refer her to pediatric psychiatry
- D. investigate social issues of the family
Correct Answer: A
Rationale: Temper tantrums are common at this age and often do not indicate pathology.
Burns are commonly seen in child abuse. Approximately 10% of children hospitalized with burns are victims of abuse. Of the following, inflicted burn can be MOST commonly the result of
- A. contact with hot iron
- B. contact with radiators
- C. cigarette application
- D. scalding injuries
Correct Answer: D
Rationale: Scalding injuries, often caused by hot liquids, are the most common type of inflicted burns in child abuse due to their accessibility and ease of use.