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A 7-year-old child has been diagnosed with rheumatic fever. Which of the following physical findings would the nurse expect to assess?
- A. Vesicular rash over the face and chest
- B. Warm and swollen knees and elbows
- C. Palpable mass in the upper right quadrant of the abdomen
- D. Yellow pigmentation of the sclera of the eyes 103 the following meets the Jone's criteria?
Correct Answer: B
Rationale: Rheumatic fever is an inflammatory condition that can affect different parts of the body, including the joints. The typical physical finding in a child with rheumatic fever is warm and swollen joints, especially in the knees and elbows. This is known as migratory arthritis and is one of the major criteria in the Jones criteria for diagnosing rheumatic fever. Other major criteria include carditis, subcutaneous nodules, erythema marginatum, and Sydenham chorea. So, in a 7-year-old child diagnosed with rheumatic fever, the nurse would expect to assess warm and swollen joints as part of the physical examination.
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Which of the following tests is most effective in diagnosing hemophilia?
- A. Bleeding time
- B. Complete blood count (CBC)
- C. Partial thromboplastin time (PTT)
- D. Platelet count
Correct Answer: C
Rationale: Partial thromboplastin time (PTT) is the most effective test in diagnosing hemophilia. Hemophilia is a genetic disorder that results in prolonged clotting times due to deficiencies in specific clotting factors, such as factor VIII (hemophilia A) or factor IX (hemophilia B). PTT is a screening test that evaluates the intrinsic pathway of coagulation and helps identify deficiencies in clotting factors. In patients with hemophilia, PTT is typically prolonged due to the reduced activity of the deficient clotting factor. Therefore, measuring PTT can aid in the diagnosis of hemophilia by assessing the clotting function and identifying specific clotting factor deficiencies. Other tests like bleeding time, CBC, and platelet count are important in evaluating overall bleeding tendencies, but they are not as specific for diagnosing hemophilia as the PTT test.
Which of the ff is the most severe complication among clients with allergies, regardless of type?
- A. Bronchitis
- B. Anaphylactic shock and angioneurotic
- C. Cardiac arrest edema
- D. Asthma and nasal polyps
Correct Answer: B
Rationale: Among clients with allergies, regardless of type, anaphylactic shock and angioneurotic edema are the most severe complications. Anaphylactic shock is a severe, potentially life-threatening allergic reaction that can occur rapidly and affect multiple organ systems, leading to a sudden drop in blood pressure and difficulty breathing. Angioneurotic edema, also known as angioedema, is another serious allergic reaction that involves swelling of the deep layers of the skin, often around the eyes and lips, but can also affect the throat and other areas, potentially leading to airway obstruction. These complications require immediate medical attention, including the administration of epinephrine and other interventions to stabilize the client.
A mother calls the school nurse saying that her daughter has developed a school phobia. She has been out of school 3 days. The nurse's recommendations should include which intervention?
- A. Immediately return the child to school.
- B. Explain to the child that this is the last day she can stay home.
- C. Determine the cause of phobia before returning the child to school.
- D. Seek professional counseling before forcing the child to return to school.
Correct Answer: C
Rationale: The appropriate intervention in this situation would be to determine the cause of the school phobia before immediately returning the child to school. School phobia, also known as school refusal, can be triggered by various factors such as bullying, academic stress, separation anxiety, or other psychological issues. By identifying the underlying cause of the phobia, the school nurse can better support the child and provide appropriate interventions to address the specific issues that are contributing to the child's reluctance to attend school. This approach helps ensure that the child receives the necessary support and resources needed to successfully reintegrate into the school environment.
The nurse interprets this as?
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Metabolic alkalosis
Correct Answer: C
Rationale: Respiratory alkalosis is a condition where there is a decrease in carbon dioxide levels in the blood due to hyperventilation, leading to an increase in pH. In respiratory alkalosis, the body is expelling too much carbon dioxide, causing the blood to become more alkaline. The nurse's interpretation of the situation as respiratory alkalosis suggests that the patient may be breathing rapidly or deeply, resulting in the elimination of excess carbon dioxide and a shift towards alkalosis.
A patient was diagnosed with hiatal hernia. She frequently has regurgitation and a sour taste on his mouth especially after eating large meals. Which action by the client shows understanding of her treatment regimen?
- A. elevate her legs when she is sleeping
- B. drink more fluids with her meals
- C. increase the roughage in her diet
- D. avoid caffeine, alcohol, and chocolate
Correct Answer: D
Rationale: Hiatal hernia is a condition where a part of the stomach pushes up through the diaphragm muscle. Symptoms often include regurgitation of stomach acid into the esophagus, leading to heartburn and a sour taste in the mouth. Avoiding triggers like caffeine, alcohol, and chocolate can help reduce acid reflux and alleviate symptoms. These substances can relax the lower esophageal sphincter and increase stomach acid production, worsening symptoms in patients with hiatal hernia. Therefore, avoiding caffeine, alcohol, and chocolate is a key aspect of managing hiatal hernia symptoms effectively. The other options provided do not directly address the underlying cause of the symptoms experienced by the patient with hiatal hernia.