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A 90 y.o. nursing home resident with stage 2 Alzheimer's disease is found alone and crying in the dining room. She says she lost her mother and doesn't know what to do. Which response by the nurse will help calm the resident?
- A. "Remember your mother has been dead for 30 years. You forgot again, didn't you?"
- B. "I'm sorry you lost your mother; let's go and try to find her."
- C. "Are you feeling frightened? I'm here and I will help you."
- D. "You are 90 years old. It is impossible for your mother to still be living. I know if you try, you can figure out what to do."
Correct Answer: C
Rationale: Option C, "Are you feeling frightened? I'm here and I will help you," is the most appropriate response to help calm the resident. The resident is experiencing confusion and distress, likely due to her Alzheimer's disease. Invalidating her feelings by reminding her of the reality may lead to more confusion and distress. Instead, acknowledging the resident's emotions, offering support, and reassuring her of your presence can help calm her down and provide comfort in the moment. It is important to provide emotional support and reassurance to individuals with Alzheimer's disease, rather than focusing on correcting their statements or reminding them of reality.
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A patient is admitted with a diagnosis of renal failure. He also mentions that he has stomach distress and ha ingested numerous antacid tablets over the past 2 days. His blood pressure is 110/70, his face is flushed, and he is experiencing generalized weakness. Choose the most likely magnesium (Mg ) value.
- A. 11mEq/L
- B. 2mEq/L
- C. 5mEq/L
- D. 1mEq/L
Correct Answer: A
Rationale: The patient's presentation suggests that he may be suffering from hypermagnesemia (high magnesium levels) due to excessive ingestion of antacid tablets. Symptoms of hypermagnesemia can include flushing, weakness, and low blood pressure. A serum magnesium level of 11mEq/L is consistent with hypermagnesemia. In this scenario, the other values (2mEq/L, 5mEq/L, 1mEq/L) are unlikely to be the correct magnesium level based on the patient's symptoms and history of antacid ingestion.
The nurse is caring for a patient on warfarin with an elevated INR level. Which of the ff. would be ordered as the antidote for warfarin?
- A. Vitamin K c.Calcium Chloride
- B. Vitamin B12
- C. Protamine Sulfate
Correct Answer: A
Rationale: Warfarin is an anticoagulant medication that works by inhibiting the production of certain clotting factors in the liver, thus prolonging the time it takes for blood to clot. An elevated INR level indicates that the blood is taking longer to clot than desired, potentially putting the patient at risk for bleeding. Vitamin K is the antidote for warfarin because it helps the liver produce these clotting factors, ultimately reversing the effects of warfarin and promoting normal blood clotting. Administering Vitamin K helps lower the INR level and reduce the risk of bleeding in patients on warfarin therapy. Therefore, in this scenario, Vitamin K would be the appropriate antidote to use for the patient with an elevated INR level.
The nurse is caring for an infant with a suspected urinary tract infection. Which clinical manifestations should be expected? (Select all that apply.)
- A. Vomiting
- B. Jaundice
- C. Failure to gain weight
- D. Swelling of the face
Correct Answer: A
Rationale: A urinary tract infection (UTI) in an infant may present with symptoms such as vomiting and failure to gain weight. Vomiting can be a common sign of UTI in infants due to irritation and inflammation in the urinary tract. Additionally, infants with UTIs may experience poor feeding and failure to gain weight due to the discomfort and systemic effects of the infection. While symptoms like jaundice, swelling of the face, back pain, and persistent diaper rash can be seen in other conditions, they are not typically associated with a urinary tract infection in infants.
Which age group should the pediatric nurse recognize as being vulnerable to events that lessen their feeling of control and power?
- A. Infants
- B. Toddlers
- C. Preschoolers
- D. School-age children
Correct Answer: A
Rationale: Infants are the age group that the pediatric nurse should recognize as being vulnerable to events that lessen their feeling of control and power. Infants are entirely dependent on others for their care and are still developing their sense of self and autonomy. They are unable to communicate their needs effectively and rely on caregivers to interpret and respond to their cues. Any disruptions in routine or changes in their environment can make infants feel insecure and powerless. Therefore, the pediatric nurse should be particularly attentive to the emotional needs and sense of control of infants when providing care.
When a child injures the epiphyseal plate from a fracture, the damage may result in which of the following?
- A. Rheumatoid arthritis
- B. Permanent nerve damage
- C. Osteomyelitis
- D. Bone growth disruption
Correct Answer: D
Rationale: The epiphyseal plate, also known as the growth plate, is the area of growing tissue near the ends of the long bones in children and adolescents. It is crucial for bone growth and development. When a child injures the epiphyseal plate from a fracture, the damage can disrupt the normal growth process of the bone. This disruption can lead to unequal limb length, angular deformities, or other growth abnormalities. Therefore, the damage resulting from an injury to the epiphyseal plate may lead to bone growth disruption. Choices A, B, and C are not directly associated with epiphyseal plate injuries.