Nokea
A 12-year-old male adolescent, recently diagnosed with Hodgkin lymphoma, shows left cervical and supraclavicular lymph node involvement and drenching night sweats. Based on Ann Arbor Classification, the patient is classified as
- A. stage IA
- B. stage IB
- C. stage IIA
- D. stage IIB
Correct Answer: D
Rationale: Involvement of two lymph node regions above the diaphragm with systemic symptoms corresponds to stage IIB.
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The nurse is working on the pediatric floor, caring for an infant who is very fussy and has a diagnosis of DI. Which parameter should the nurse monitor while the infant is on fluid restrictions?
- A. Oral intake.
- B. Urine output.
- C. Appearance of the mucous membranes.
- D. Pulse and temperature. 116
Correct Answer: B
Rationale: In a patient with diabetes insipidus (DI) who is on fluid restrictions, monitoring urine output is crucial to assess the effectiveness of the treatment regimen. DI is a condition characterized by excessive urination and thirst due to a deficiency of antidiuretic hormone (ADH). By monitoring urine output, the nurse can determine if the restrictions are achieving the goal of decreasing urine volume and preventing dehydration. Changes in urine output can also indicate the need for adjustments in the treatment plan. Monitoring oral intake, appearance of mucous membranes, and pulse and temperature are important aspects of pediatric care but are not as directly related to managing fluid restrictions in a patient with DI.
When evaluating the effectiveness of nursing interventions for sinusitis discomfort, which of the following does the nurse assess?
- A. WBC count
- B. Capillary refill
- C. Amount and color of sinus drainage
- D. Comfort level
Correct Answer: C
Rationale: When evaluating the effectiveness of nursing interventions for sinusitis discomfort, assessing the amount and color of sinus drainage is crucial. Changes in these aspects can provide valuable information about the progression of the sinusitis and the effectiveness of the interventions being implemented. Increased or purulent sinus drainage can indicate infection or inflammation, while clearer drainage may suggest improvement. Monitoring these parameters helps the nurse make informed decisions about continuing, modifying, or discontinuing interventions to manage the patient's sinusitis discomfort effectively. Evaluating WBC count, capillary refill, and comfort level are also important assessments in certain situations, but assessing the amount and color of sinus drainage is most directly related to sinusitis symptoms.
The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. How should this action be interpreted?
- A. Inappropriate, because of child's age
- B. A way to establish rapport
- C. Too distracting, when cooperation is important
- D. Acceptable, if there is adequate time
Correct Answer: B
Rationale: Using a simple magic trick with gauze to engage a 5-year-old child during a dressing change is a way to establish rapport. This approach can help build trust and reduce anxiety by making the procedure more engaging and less intimidating for the child. By creating a positive interaction through a fun activity, the nurse can promote cooperation and make the dressing change a smoother experience for the child. Overall, the use of a magic trick in this context is appropriate and beneficial for enhancing the child's cooperation and comfort.
Regarding physical growth of preschool children (3-5 years), all are true EXCEPT
- A. 7-8 kg weight increment/yr
- B. 20 primary teeth erupted by 3 years
- C. brain stops myelinization by 8 years
- D. height increment/yr average is 5-6 cm up to 18 years
Correct Answer: A
Rationale: Weight increment varies and is generally less than 7-8 kg/yr.
The nurse is planning care for a family expecting their newborn to die. The nurse's interventions should be based on which statement?
- A. Tangible remembrances of the newborn (e.g., lock of hair, picture) prolong grief.
- B. Photographs of newborns should not be taken after the death has occurred.
- C. Funerals are not recommended because mother is still recovering from childbirth.
- D. Parents should be encouraged to name their newborn if they have not done so already.
Correct Answer: D
Rationale: Parents should be encouraged to name their newborn if they have not done so already because giving the baby a name can help the parents acknowledge their baby as a unique individual. It can also provide a sense of connection and identity, which can be important for the grieving process and coping with the loss. Naming the baby allows the parents to honor their child's existence and memory, and it can be a meaningful part of their healing journey.