Nokea
A 16-year-old, 165-pound patient reports consuming 20-40 325-mg capsules containing acetaminophen 1 hour ago. You should
- A. measure the plasma level and determine potential toxicity from the level on the nomogram
- B. wait until 4 hours after ingestion to measure the plasma level and do nothing else
- C. administer activated charcoal immediately and measure the plasma level of acetaminophen 4 hours after ingestion
- D. send the patient home because an ingestion of this magnitude is not toxic
Correct Answer: C
Rationale: Activated charcoal can help reduce absorption of acetaminophen, and plasma levels should be measured 4 hours post-ingestion to assess toxicity using the nomogram.
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When a child injures the epiphyseal plate from a fracture, the damage may result in which of the following?
- A. Rheumatoid arthritis
- B. Permanent nerve damage
- C. Osteomyelitis
- D. Bone growth disruption
Correct Answer: D
Rationale: The epiphyseal plate, also known as the growth plate, is the area of growing tissue near the ends of the long bones in children and adolescents. It is crucial for bone growth and development. When a child injures the epiphyseal plate from a fracture, the damage can disrupt the normal growth process of the bone. This disruption can lead to unequal limb length, angular deformities, or other growth abnormalities. Therefore, the damage resulting from an injury to the epiphyseal plate may lead to bone growth disruption. Choices A, B, and C are not directly associated with epiphyseal plate injuries.
A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result?
- A. Negative Coombs test
- B. Bleeding from the nose and ear
- C. Jaundice after the first 24 hours of life
- D. Jaundice within the first 24 hours of life
Correct Answer: D
Rationale: A neonate born to a mother with blood type AB and a father with blood type O is at risk for ABO blood incompatibility, particularly if the neonate is blood type A or B. The major sign of ABO blood incompatibility in the neonate is the development of jaundice within the first 24 hours of life. This occurs due to the mismatch in blood types between the mother and the neonate, leading to the destruction of the neonate's red blood cells. This destruction releases bilirubin, causing jaundice. It is important to note that unlike Rh incompatibility, ABO incompatibility usually does not lead to severe complications requiring treatment. A positive Coombs test result is not typically seen in ABO blood incompatibility.
The baby with newly diagnosed diabetes is displaying shakiness, confusion, irritability, and slurred speech. What should the nurse suspect is happening?
- A. DKA
- B. Hypoglycemia
- C. HHS
- D. Hyperglycemia
Correct Answer: B
Rationale: The baby's symptoms of shakiness, confusion, irritability, and slurred speech are indicative of hypoglycemia, which is low blood sugar. In a baby with newly diagnosed diabetes, the administration of insulin or oral hypoglycemic agents may have led to excessive lowering of blood glucose levels, causing these symptoms to manifest. It is crucial to address hypoglycemia promptly by administering a rapid-acting carbohydrate source such as glucose gel or juice to raise blood sugar levels back to normal range. Left untreated, severe hypoglycemia can lead to seizures, loss of consciousness, and potential long-term neurological damage. It is important for healthcare providers and caregivers to be vigilant in monitoring blood glucose levels in babies newly diagnosed with diabetes to prevent episodes of hypoglycemia.
A 3-year-old with croup has the following vital signs: HR 90, RR 44, BP 100/52, T 98.8°F. The parents ask if these are normal. The nurse's best response is:
- A. Your son's blood pressure is elevated.
- B. Your son's temperature is elevated.
- C. Your son's respiratory rate is elevated; a normal rate for his age is 20-30 breaths per minute.
- D. Your son's heart rate is elevated.
Correct Answer: C
Rationale: The elevated respiratory rate is concerning since normal for a 3- to 6-year-old is about 20-30 breaths per minute.
Will is being assessed by Nurse Lucas for possible intussusception; which of the following would be least likely to provide valuable information?
- A. Abdominal palpation
- B. Family history
- C. Pain pattern
- D. Stool inspection
Correct Answer: B
Rationale: When assessing a patient like Will for possible intussusception, the least likely to provide valuable information would be the family history. While family history can help identify potential genetic predispositions or conditions that may contribute to a patient's current health concerns, in this case, the focus is on Will's immediate symptoms and diagnostic indicators related to possible intussusception. Abdominal palpation, pain pattern assessment, and stool inspection are more directly relevant to evaluating Will's current condition and determining the likelihood of intussusception. Family history, while important in a broader health context, would be least likely to provide immediate insights into Will's specific situation with intussusception.