Nokea
A 16-year-old male with cystic fibrosis is hospitalized for 2 weeks for IV antibiotics. Which action will most enhance his psychosocial development?
- A. Fax his teacher and have homework sent in.
- B. Encourage his friends to visit him in the hospital.
- C. Encourage frequent visits from his grandparents.
- D. Allow him unlimited phone use to contact friends.
Correct Answer: B
Rationale: Peer interactions are crucial during adolescence; having friends visit helps him feel connected and 'normal.'
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The nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority?
- A. Disturbed body image related to changes in body functions
- B. Ineffective airway clearance related to obstruction by a tumor or secretions
- C. Anxiety related to actual threat to health status and changes in family dynamics
- D. Imbalanced nutrition: Less than body requirements related to anorexia and vomiting secondary to chemotherapy
Correct Answer: B
Rationale: In caring for a client with bronchogenic carcinoma, the highest priority nursing diagnosis would be Ineffective airway clearance related to obstruction by a tumor or secretions. This is crucial because any blockage in the airway can lead to serious respiratory complications, such as respiratory distress or respiratory failure. Ensuring effective airway clearance is essential to maintain adequate oxygenation and ventilation for the client. Addressing this priority nursing diagnosis promptly can help prevent potential life-threatening situations and promote optimal respiratory function for the client.
Which of the following data would be included in a health history? (Select all that apply.)
- A. Review of systems
- B. Physical assessment
- C. Sexual history
- D. Growth measurements
Correct Answer: A
Rationale: A health history is a comprehensive compilation of information about a patient's health status, medical conditions, and pertinent background information. The selected data that would be included in a health history includes:
Mr. Reyea complains of hearing ringing noises. The nurse recognizes that this assessment suggests injury of the
- A. Frontal lobe
- B. Six cranial nerve (abducent)
- C. Occipital lobe
- D. Eight Cranial Nerve (Vestibulocochlear)
Correct Answer: D
Rationale: The eighth cranial nerve is the vestibulocochlear nerve, which is responsible for transmitting auditory and balance information from the inner ear to the brain. Complaints of hearing ringing noises, also known as tinnitus, suggest a dysfunction or injury to the vestibulocochlear nerve. Tinnitus is a common symptom of various inner ear disorders such as noise-induced hearing loss, Meniere's disease, or acoustic neuroma. Therefore, the nurse should investigate further for possible issues related to the vestibulocochlear nerve when a patient reports hearing ringing noises.
The physical abuse of children by parents affects children of all ages. It is estimated that 1% to 2% of children are physically abused during childhood and that significant number of them are fatally injured each year. Of the following, the second LEADING cause of mortality from physical abuse is
- A. rib fractures
- B. head trauma
- C. abdominal injury
- D. hot tap water burn
Correct Answer: B
Rationale: Head trauma is a leading cause of mortality in abused children, as it can result in severe brain damage or death.
The nurse is caring for a school-age child with a tinea capitis (ringworm) infection. What should the nurse expect the therapeutic management of this child to include?
- A. Administering oral griseofulvin
- B. Administering topical or oral antibiotics
- C. Applying topical sulfonamides
- D. Applying Burow solution compresses to affected area
Correct Answer: A
Rationale: The nurse should expect the therapeutic management of a school-age child with tinea capitis to include administering oral griseofulvin. Griseofulvin is an antifungal medication commonly used to treat fungal infections like tinea capitis. Topical or oral antibiotics are not effective in treating fungal infections. Applying topical sulfonamides is also not a recommended treatment for tinea capitis. Burow solution compresses are used to provide relief for inflammatory skin conditions and are not specific treatments for fungal infections like tinea capitis.