Nokea
A 15-year-old has been admitted to the hospital with the diagnosis of acute lymphocytic leukemia. Which of the following signs and symptoms require the most immediate nursing intervention?
- A. An enlarged liver and spleen
- B. Fatigue
- C. Fever and petechiae
- D. Swollen glands and lethargy
Correct Answer: C
Rationale: The correct answer is C: Fever and petechiae. Fever and petechiae are indicative of a potential infection or bleeding, which can be life-threatening for a leukemia patient due to compromised immune system and low platelet count. Immediate nursing intervention would involve assessing the severity of the fever, monitoring for signs of sepsis, and addressing any bleeding issues.
A: An enlarged liver and spleen may be common in leukemia but do not require immediate intervention unless associated with other symptoms.
B: Fatigue is common in leukemia but not as urgent as signs of infection or bleeding.
D: Swollen glands and lethargy are also common in leukemia but do not require immediate intervention unless accompanied by other concerning symptoms.
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A school-aged client admitted to the hospital because of decreased urine output and periorbital edema is diagnosed with glomerulonephritis. Which of the following interventions should receive the highest priority?
- A. Assessing vital signs every four hours
- B. Monitoring intake and output every 12 hours
- C. Obtaining daily weight measurements
- D. Obtaining serum electrolyte levels daily
Correct Answer: C
Rationale: The correct answer is C: Obtaining daily weight measurements. Daily weight measurements are crucial in monitoring fluid status in clients with glomerulonephritis, as sudden weight gain can indicate fluid retention and worsening of the condition. This intervention allows for early detection of fluid imbalances, guiding appropriate fluid management and treatment adjustments.
Assessing vital signs every four hours (choice A) is important but not the highest priority in this scenario, as monitoring weight is more specific for fluid status changes. Monitoring intake and output every 12 hours (choice B) is also important, but not as immediate as obtaining daily weight measurements. Obtaining serum electrolyte levels daily (choice D) is essential, but weight measurements take precedence in assessing fluid status.
After taking an HIV antibody test the patient is required to wait:
- A. 30 days
- B. 1 hour
- C. 30 minutes
- D. 10 minutes
Correct Answer: C
Rationale: The correct answer is C: 30 minutes. After taking an HIV antibody test, the patient is required to wait for 30 minutes before the results can be accurately interpreted. This waiting period allows for the proper reaction time for the test results to develop. Waiting for 30 minutes ensures that any potential errors or discrepancies in the test results are minimized.
Choice A (30 days) is incorrect as waiting this long is unnecessary and impractical for obtaining HIV test results. Choice B (1 hour) and Choice D (10 minutes) are incorrect as they do not align with the standard waiting time recommended for HIV antibody tests. Waiting for 30 minutes strikes a balance between allowing sufficient time for accurate results while not unnecessarily prolonging the waiting period.
The mother of a toddler is concerned because her child does not seem interested in eating. The child is drinking five to six cups of whole milk per day and one cup of fruit juice. When the weight-to-height percentile is calculated, the child is in the 90th to 95th percentile. What is the best advice the nurse can provide to the mother?
- A. Eliminate the fruit juice from the child’s diet.
- B. Offer healthy snacks, presented in a creative manner, and let the child choose what he wants to eat without pressure from the parents.
- C. Change from whole milk to 2 percent milk and decrease milk consumption to three to four cups per day and the fruit juice to a half cup per day, offering water if the child is still thirsty in between.
- D. Make sure that the child is getting adequate opportunities for exercise, as this will increase his appetite and help lower the child’s weight-to-height percentile.
Correct Answer: C
Rationale: Step 1: Whole milk is high in saturated fat and calories, contributing to excessive weight gain. Switching to 2 percent milk reduces fat intake.
Step 2: Decreasing milk consumption and limiting fruit juice helps balance calorie intake and encourages the child to eat solid foods.
Step 3: Offering water in between meals ensures hydration without additional calories.
Step 4: Adjusting the child's diet in this manner promotes healthier eating habits and can help normalize weight-to-height percentile.
In summary, option C is correct as it addresses the concerns of excessive milk and juice consumption while promoting a balanced diet.
Options A, B, and D are incorrect because eliminating fruit juice alone may not address the overall calorie intake issue. Healthy snacks and creative presentation may not address the specific problem of excessive milk consumption. Increasing exercise alone may not directly impact the child's diet and weight-to-height percentile.
There are 3 classifications of Anemia. What are they?
- A. Inadequate production of Hb
- B. Decreased RBC production
- C. Increased Erythrocyte destruction
- D. Blood loss
Correct Answer: A
Rationale: The correct answer is A: Inadequate production of Hb. Anemia is classified based on the underlying mechanism causing decreased hemoglobin levels. Inadequate production of hemoglobin is one of the classifications, encompassing conditions like iron deficiency anemia. Decreased RBC production (choice B) is a broader classification that includes various causes like bone marrow disorders. Increased erythrocyte destruction (choice C) refers to hemolytic anemias where red blood cells are destroyed prematurely. Blood loss (choice D) is a separate classification related to acute or chronic bleeding. Therefore, the correct answer specifically addresses the primary issue of insufficient hemoglobin production in anemia.
Which one of the following does NOT contain C3b?
- A. classic-pathway C5 convertase
- B. alternative-pathway C5 convertase
- C. classic-pathway C3 convertase
- D. alternative-pathway C3 convertase
Correct Answer: C
Rationale: The correct answer is C because classic-pathway C3 convertase does not contain C3b. In the classical pathway, C3 convertase is formed by the cleavage of C4bC2a, which does not involve C3b.
A: classic-pathway C5 convertase contains C3b as it is formed by the binding of C4b2a3b complex to C5.
B: alternative-pathway C5 convertase contains C3b as it is formed by the binding of C3bBb3b complex to C5.
D: alternative-pathway C3 convertase contains C3b as it is formed by the binding of C3bBb complex to C3.