Nokea
A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority?
- A. Instituting droplet precautions
- B. Administering acetaminophen (Tylenol)
- C. Obtaining history information from the parents
- D. Orienting the parents to the pediatric unit
Correct Answer: A
Rationale: Droplet precautions are essential to prevent the spread of meningococcal meningitis to others.
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A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will need to stop eating so much chili to keep that indigestion pain from returning. How should the nurse respond?
- A. Chili is high in fat and calories; it would be a good idea to stop eating it.
- B. The provider has prescribed an antacid for you to take every morning.
- C. What do you understand about what happened to you?
- D. When did you start experiencing this indigestion?
Correct Answer: C
Rationale: Assessing the client’s understanding of their condition helps the nurse provide appropriate education and address misconceptions about symptoms.
A 3-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. Which sign or symptom suggests excessive I.V. fluid intake?
- A. Worsening dyspnea
- B. Gastric distension
- C. Nausea and vomiting
- D. Temperature of 102°F (38.9° C)
Correct Answer: A
Rationale: Worsening dyspnea may indicate fluid overload, leading to pulmonary edema and respiratory distress.
Guillain-Barre syndrome (GBS) is excluded by:
- A. A normal CSF
- B. The presence of autonomic neuropathy
- C. Distinct sensory level
- D. Ophthalmoplegia
Correct Answer: C
Rationale: A distinct sensory level is not a feature of GBS, which typically presents with ascending symmetrical weakness and absent reflexes.
A 4-year-old child has had fever, malaise, and vomiting and right-sided abdominal pain for 48 hours. The following are likely diagnoses:
- A. Acute pyelonephritis
- B. Shigella dysentery
- C. Ascaris lumbricoides infestation, if the child is living in the tropics
- D. Right sided tumour
Correct Answer: A
Rationale: Acute pyelonephritis is a common cause of fever, vomiting, and abdominal pain in children. Shigella dysentery typically causes diarrhea, and Ascaris infestation is rare in non-tropical regions. A right-sided tumour is unlikely without other signs.
The family suspects that AIDS dementia is occurring in their son who is HIV positive. Which symptom confirms their suspicions?
- A. A change has recently occurred in his handwriting.
- B. The client has a persistent cough and fever.
- C. The client experiences shortness of breath.
- D. The client exhibits a loss of appetite.
Correct Answer: A
Rationale: Changes in handwriting may indicate cognitive decline, a hallmark of AIDS dementia.