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A 16-year-old female student with a history of asthma controlled with both an oral antihistamine and an albuterol (Proventil) metered-dose inhaler (MDI) comes to the school nurse. The student complains that she cannot sleep at night, feels shaky and her heart feels like it is 'beating a mile a minute.' Which information is most important for the nurse to obtain?
- A. When she last took the antihistamine.
- B. When her last asthma attack occurred.
- C. Duration of most asthma attacks.
- D. How often the MDI is used daily.
Correct Answer: D
Rationale: The most important information for the nurse to obtain in this scenario is how often the MDI is used daily. This is crucial to assess if the symptoms the student is experiencing, such as insomnia, shakiness, and tachycardia, could be related to overuse of the inhaler. Overuse of albuterol can lead to side effects like tremors, palpitations, and difficulty sleeping, so understanding the frequency of MDI use is key in determining a potential cause for the student's symptoms.
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A child with leukemia is admitted for chemotherapy, and the nursing diagnosis 'altered nutrition, less than body requirements related to anorexia, nausea, and vomiting' is identified. Which intervention should the nurse include in this child's plan of care?
- A. Encourage a variety of large portions of food at every meal.
- B. Allow the child to eat any food desired and tolerated.
- C. Recommend eating the food as siblings eat at home.
- D. Restrict food brought from fast-food restaurants.
Correct Answer: B
Rationale: Allowing the child to eat any food desired and tolerated is the most appropriate intervention in this scenario. Anorexia, nausea, and vomiting are common side effects of chemotherapy, which can lead to altered nutrition. Allowing the child to choose foods they desire and can tolerate can help improve their nutritional intake during this challenging time.
Following a motor vehicle collision, a 3-year old girl has a spica cast applied. Which toy is best for the nurse for this 3 year old child?
- A. Duck that squeaks.
- B. Fashion doll and clothes.
- C. Set of cloth and hand puppets.
- D. Hand held video game.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What information should the nurse provide to parents of a 3-year-old boy with Duchenne muscular dystrophy who inquire about the disease and future children?
- A. This is an inherited X-linked recessive disorder, which primarily affects male children in the family
- B. The striated muscle groups of males can be impacted by a lack of the protein dystrophin in their mothers
- C. The male infant had a viral infection that went unnoticed and untreated so muscle damage was incurred
- D. Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles
Correct Answer: A
Rationale: Duchenne muscular dystrophy is an X-linked recessive disorder caused by mutations in the DMD gene on the X chromosome. This disorder primarily affects males because they have one X chromosome, inherited from their mothers, who may be carriers of the mutated gene. Females have two X chromosomes, providing a protective effect as the normal gene on one X chromosome can compensate for the mutated gene on the other. Therefore, the nurse should explain to the parents that Duchenne muscular dystrophy is an inherited X-linked recessive disorder, which is why their son has the disease and why there is a risk of passing it on to future sons.
The nurse is assessing a 4-month-old infant who has just received routine immunizations. The mother reports that the baby has been fussy and has a low-grade fever since the immunizations. What is the best response by the nurse?
- A. These are common side effects and should resolve within a few days
- B. Your baby may be having an allergic reaction to the immunizations
- C. You should bring your baby to the clinic immediately for evaluation
- D. You should give your baby aspirin to help with the fever
Correct Answer: A
Rationale: Fussiness and low-grade fever are common side effects of immunizations in infants and usually resolve on their own. It is important for the nurse to educate the mother about these expected reactions to help ease her concerns. Immediate evaluation or giving aspirin to an infant for fever is not necessary or safe, as aspirin can be harmful to infants.
Which nursing diagnosis is a priority for a 4-year-old child diagnosed with nephrotic syndrome?
- A. Impaired urinary elimination.
- B. Risk for infection.
- C. Fluid volume excess.
- D. Risk for impaired skin integrity.
Correct Answer: C
Rationale: In a child with nephrotic syndrome, fluid volume excess is a priority nursing diagnosis due to the risk of edema and related complications. This patient may experience significant fluid retention, leading to edema, hypertension, and potential respiratory distress. Monitoring and managing fluid volume excess are crucial in preventing further complications and supporting the child's health during nephrotic syndrome.