Nokea
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.
You may also like to solve these questions
is a Self - Limiting disease that affects of femoral head :
- A. Coxa
- B. JRA
- C. Rickets
- D. DDH
Correct Answer: C
Rationale: Rickets is a self-limiting disease that affects the growth plates in bones, including the femoral head. It is primarily caused by a deficiency in vitamin D, which is necessary for proper bone mineralization and growth. Rickets is more common in children and can lead to weakened bones, deformities, and growth disturbances. With proper treatment and supplementation, rickets can be reversed and often resolves once the underlying vitamin D deficiency is addressed.
For a 14-month-old whose cleft palate was repaired 12 hours ago, which should be included in the plan of care?
- A. Allow familiar comfort items (e.g., favorite stuffed animal) and a 'sippy' cup (avoid suction items).
- B. Once liquids are tolerated, encourage a bland diet (e.g., soup, Jell-O, saltine crackers).
- C. Administer scheduled pain medication rather than PRN only.
- D. Use a Yankauer suction catheter to decrease aspiration risk.
Correct Answer: A
Rationale: Providing comfort items and avoiding suction items helps reduce distress and supports healing.
Kasabach-Merritt syndrome is characterized by all the following EXCEPT
- A. thrombocytopenia
- B. microangiopathic hemolytic anemia
- C. coagulopathy
- D. association with infantile hemangiomas
Correct Answer: D
Rationale: Kasabach-Merritt syndrome is not typically associated with hemangiomas.
. During the first 24 hours after a client is diagnosed with Addisonian crisis, which of the following should the nurse perform frequently?
- A. Weigh the client.
- B. Administer oral hydrocortisone.
- C. Test urine for ketones.
- D. Assess vital signs.
Correct Answer: D
Rationale: During the first 24 hours after a client is diagnosed with Addisonian crisis, it is crucial for the nurse to frequently assess the client's vital signs. Addisonian crisis is a life-threatening condition resulting from acute adrenal insufficiency. Monitoring vital signs such as blood pressure, heart rate, respiratory rate, and temperature can provide valuable information about the client's condition and response to treatment. Changes in vital signs may indicate worsening or improvement in the client's health status, helping the nurse to make timely interventions and adjustments in the client's care plan. Regular assessment of vital signs is essential in managing the client's stability and preventing complications during this critical period.
A nurse is planning to use an interpreter during a health history interview of a non-English speaking patient and family. Which nursing care guidelines should the nurse include when using an interpreter? (Select all that apply.)
- A. Elicit one answer at a time.
- B. Interrupt the interpreter if the response from the family is lengthy.
- C. Comments to the interpreter about the family should be made in English.
- D. Arrange for the family to speak with the same interpreter, if possible.
Correct Answer: A
Rationale: Elicit one answer at a time: By eliciting one answer at a time, the nurse can ensure clarity in communication and prevent confusion or information overload for both the patient and interpreter.