Nokea
A 13-year-old has been admitted with a diagnosis of rheumatic fever and is on bed rest. He complains of a sore throat. His joints are painful and swollen. He has a red rash on his trunk and is experiencing aimless movements of his extremities. Use the chart below to determine what the nurse should do first.
- A. Report the heart rate to the physician.
- B. Apply lotion to the rash.
- C. Splint the joints to relieve the pain.
- D. Request an order for medication to treat the elevated temperature.
Correct Answer: A
Rationale: Rheumatic fever can cause carditis, and an elevated heart rate may indicate cardiac involvement, requiring immediate reporting. Other symptoms are managed after assessing cardiac status.
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The nurse begins CPR on a 5-year-old unresponsive client. When the emergency response team arrives, the child continues to have no respiratory effort but has a heart rate of 50 with cyanotic legs. The team should next:
- A. Discontinue compressions but continue administering breaths with a bag-mask device.
- B. Establish an intravenous line with a large bore needle while preparing the defibrillator.
- C. Begin 2-person CPR at a ratio of 2 breaths to 15 compressions.
- D. Begin 2-person CPR at a ratio of 2 breaths to 30 compressions.
Correct Answer: C
Rationale: For a 5-year-old with a heart rate of 50 (bradycardia) and no respiratory effort, 2-person CPR with a ratio of 2 breaths to 15 compressions is appropriate to optimize oxygenation and circulation.
When assessing a 4-month-old infant diagnosed with possible intussusception, the nurse should expect the mother to relate which of the following about the infant's crying and episodes of pain?
- A. Constant accompanied by leg extension.
- B. Intermittent with knees drawn to the chest.
- C. Shrill during ingestion of solids.
- D. Intermittent while being held in the mother's arms.
Correct Answer: B
Rationale: Intussusception causes intermittent pain with knees drawn to the chest due to bowel obstruction.
An adolescent girl with a seizure disorder controlled with phenytoin (Dilantin) and carbamazepine (Tegretol) asks the nurse about getting married and having children. Which of the following responses by the nurse would be most appropriate?
- A. You probably shouldn't consider having children until your seizures are cured.'
- B. Your children won't necessarily have an increased risk of seizure disorder.'
- C. When you decide to have children, talk to the doctor about changing your medication.'
- D. Women with seizure disorders commonly have a difficult time conceiving.'
Correct Answer: C
Rationale: Consulting a doctor about medication adjustments before pregnancy ensures safety for mother and fetus, addressing teratogenic risks.
The mother of a toddler with nephrotic syndrome asks the nurse what can be done about the child's swollen eyes. Which measure should the nurse suggest?
- A. Applying cool compresses to the child's eyes.
- B. Elevating the head of the child's bed.
- C. Applying eye drops every 8 hours.
- D. Limiting the child's television watching.
Correct Answer: B
Rationale: Elevation reduces swelling.
A 14-year-old has just had a plaster cast placed on his lower left leg. To provide safe cast care, the nurse should?
- A. Petal the cast as soon as it is put on.
- B. Keep the child in the same position for 24 hours until the cast is dry.
- C. Use only the palms of the hand when handling the cast.
- D. Notify the physician if the client complains of heat.
Correct Answer: C
Rationale: Using only the palms prevents indentations in the wet cast, which could cause pressure points or alter the cast's shape.