Nokea
A child admitted with extensive burns. The nurse notes that there are burns on the child's lips and singed nasal hairs. The nurse should suspect that the child has a(n):
- A. Chemical burn
- B. Inhalation injury
- C. Electrical burn
- D. Hot-water scald
Correct Answer: B
Rationale: The correct answer is B: Inhalation injury. The presence of burns on the lips and singed nasal hairs indicate that the child has likely inhaled hot gases or smoke, which can cause damage to the respiratory tract. This is a common finding in cases of inhalation injury resulting from exposure to fire or smoke. Inhalation injury can lead to airway compromise, respiratory distress, and other serious complications. The other choices (A: Chemical burn, C: Electrical burn, D: Hot-water scald) do not specifically indicate damage to the respiratory tract, making them less likely in this scenario.
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Which is the most accurate genetic explanation for a family with hemophilia?
- A. It is an X-linked recessive disorder
- B. It is an autosomal recessive disorder
- C. It is equally distributed among males and females
- D. It is a Y-linked dominant disorder
Correct Answer: A
Rationale: The correct answer is A: It is an X-linked recessive disorder. Hemophilia is caused by a mutation in genes located on the X chromosome. Males inherit the disorder from their mothers, as they only inherit one X chromosome. Females can be carriers if they inherit one mutated X chromosome. Autosomal recessive disorders (choice B) require both parents to pass on the mutated gene. Hemophilia is not equally distributed among males and females (choice C) because males are more likely to exhibit symptoms. Y-linked disorders (choice D) are inherited only by males and are passed from father to son.
Which are appropriate actions to manage a hospitalized child with hemophilia? (Select all that apply).
- A. Administer Factor VII for bleeding crises
- B. Administer platelets for bleeding crises
- C. Avoid unnecessary skin punctures
- D. Administer Ibuprofen for complaints of discomfort
Correct Answer: A,C
Rationale: The correct answers are A and C. Administering Factor VII helps in managing bleeding crises in hemophiliac patients. Factor VII aids in clotting, essential for stopping bleeding. Avoiding unnecessary skin punctures reduces the risk of bleeding episodes in hemophilia patients. Platelets (B) and Ibuprofen (D) are not appropriate for managing hemophilia. Platelets do not address the underlying clotting factor deficiency in hemophilia, and Ibuprofen can worsen bleeding due to its antiplatelet effects.
A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child's dressing. Which of the following actions should the nurse take?
- A. Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site.
- B. Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site.
- C. Apply continuous pressure 2.5 cm (1 in) below the percutaneous skin site.
- D. Apply intermittent pressure 2.5 cm (1 in) above the percutaneous skin site.
Correct Answer: C
Rationale: Correct Answer: C
Rationale: Applying continuous pressure 2.5 cm below the percutaneous skin site will help control bleeding by promoting clot formation at the catheter insertion site. This pressure point is closer to the source of bleeding, ensuring better hemostasis and preventing further complications.
Summary:
A: Applying intermittent pressure below the site is incorrect as continuous pressure is more effective in achieving hemostasis.
B: Applying continuous pressure above the site is incorrect as it does not target the bleeding source directly.
D: Applying intermittent pressure above the site is incorrect as continuous pressure is preferred for controlling bleeding.
E, F, G: No information provided.
Which of the following is a serious complication of acute rheumatic fever?
- A. Seizures
- B. Coronary aneurysms
- C. Pulmonary hypertension
- D. Cardiac valve damage
Correct Answer: D
Rationale: The correct answer is D: Cardiac valve damage. Acute rheumatic fever can lead to inflammation of the heart valves, causing damage and leading to conditions like mitral stenosis or regurgitation. This occurs due to an autoimmune response triggered by a previous streptococcal infection. Choice A, seizures, is not typically associated with acute rheumatic fever. Choice B, coronary aneurysms, is more commonly linked to conditions like Kawasaki disease. Choice C, pulmonary hypertension, is not a typical complication of acute rheumatic fever. Thus, the correct answer is D, as it aligns with the known pathophysiology of the disease.
When caring for a patient with Syndrome of inappropriate Antidiuretic Hormone Secretion (SIADH), the nurse would expect her patient to exhibit the following clinical signs and symptoms (Select all that apply):
- A. Fluid retention
- B. Hypotonicity
- C. Anorexia
- D. Frequent urination
Correct Answer: A,B,C
Rationale: Step-by-step rationale:
A: Fluid retention - In SIADH, there is excessive ADH secretion leading to water retention and dilutional hyponatremia.
B: Hypotonicity - Due to water retention, serum osmolality decreases leading to hypotonicity.
C: Anorexia - SIADH can cause nausea, vomiting, and anorexia due to hyponatremia and cerebral edema.
Incorrect choices:
D: Frequent urination - SIADH causes water retention, leading to decreased urine output, not frequent urination.