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A 2-year-old is noted to be drinking from a container filled with kerosene. He immediately coughs, becomes tachypneic, and is brought to the hospital. The best approach to his treatment is to
- A. induce emesis
- B. perform nasogastric tube lavage
- C. instill mineral oil
- D. administer steroids
Correct Answer: E
Rationale: Inducing emesis or performing gastric lavage can increase the risk of aspiration. The best approach is supportive care, including oxygen and monitoring.
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The client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction?
- A. Space the administration every 4 hours.
- B. Use the drug for a short time only
- C. Take piroxicam with food or oral antacid
- D. Decrease the piroxicam dosage
Correct Answer: C
Rationale: Piroxicam is a nonselective NSAID (nonsteroidal anti-inflammatory drug) that can irritate the gastrointestinal (GI) tract, leading to symptoms such as heartburn, indigestion, and stomach pain. Taking piroxicam with food or an oral antacid can help reduce GI irritation by providing a protective barrier and reducing acid production within the stomach. Encouraging the client to take piroxicam with a meal or antacid can help prevent or minimize GI upset associated with the medication. Additionally, using a proton pump inhibitor (PPI) or histamine-2 receptor antagonist (H2 blocker) along with piroxicam may further protect the stomach lining from irritation.
Antihistamines are used cautiously in older men with prostatic hypertrophy for which of the ff reasons?
- A. Because the clients may experience increased drowsiness
- B. Because these clients may experience difficulty voiding
- C. Because these clients face a greater risk of cardiac arrest
- D. Because these clients have a lower autoimmune response CARING FOR CLIENTS WITH AIDS
Correct Answer: B
Rationale: Antihistamines are used cautiously in older men with prostatic hypertrophy (enlarged prostate) because these clients may experience difficulty voiding. Antihistamines can cause urinary retention by causing decreased bladder contractility and relaxation of the bladder neck muscles. In individuals with prostatic hypertrophy, there is already an increased risk of urinary retention due to obstruction caused by the enlarged prostate. Therefore, the use of antihistamines can exacerbate this condition, leading to further difficulty in urination. It is important to monitor these individuals closely and consider alternative medications that do not pose a risk of worsening urinary symptoms.
The nurse is taking a health history on an adolescent. Which best describes how the chief complaint should be determined?
- A. Ask for detailed listing of symptoms.
- B. Ask adolescent, "Why did you come here today?"
- C. Use what adolescent says to determine, in correct medical terminology, what the problem is.
- D. Interview parent away from adolescent to determine chief complaint.
Correct Answer: B
Rationale: When determining the chief complaint for an adolescent during a health history, the best approach is to directly ask the adolescent, "Why did you come here today?" This allows the nurse to understand the reason for the visit from the adolescent's perspective and helps in identifying the primary concern or reason for seeking medical care. Adolescent patients should be encouraged to express their own concerns and symptoms in their own words, which can help in building trust and promoting open communication between the nurse and the patient. It is important to prioritize the adolescent's input in determining the chief complaint, as it relates to their own health and well-being.
The birthweight usually quadruples by the age of
- A. 1.5 yr
- B. 2 yr
- C. 2.5 yr
- D. 3 yr
Correct Answer: B
Rationale: Birthweight typically quadruples by 2 years of age.
A patient is admitted with symptoms of a recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs. Which of the following nursing diagnoses is most appropriate for this patient's plan of care?
- A. Deficient fluid volume
- B. Imbalanced nutrition more than body requirements
- C. Excess fluid volume
- D. Noncompliance
Correct Answer: C
Rationale: The patient's symptoms of recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs are indicative of fluid volume excess. These signs and symptoms suggest that the patient is retaining too much fluid, leading to the edema and congestion in the lungs. The nursing diagnosis of Excess Fluid Volume is appropriate for this patient as it reflects the patient's current physiological state and guides the plan of care to address excess fluid accumulation through interventions such as diuretic therapy, fluid restriction, and monitoring of intake and output. Deficient fluid volume, Imbalanced nutrition more than body requirements, and Noncompliance are not appropriate nursing diagnoses given the patient's presentation of fluid overload.