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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The nurse caring for an adolescent patient with a diagnosis of goiter knows that goiter is most often caused by?
- A. Kawasaki's disease
- B. Takayasu Disease
- C. Matsuzaki Disease
- D. Hashimoto Disease
Correct Answer: D
Rationale: The correct answer is D: Hashimoto Disease. Goiter is most commonly caused by Hashimoto Disease, which is an autoimmune condition where the body attacks the thyroid gland, leading to inflammation and enlargement of the gland. This results in the development of a goiter. Kawasaki's disease (A), Takayasu Disease (B), and Matsuzaki Disease (C) are not typically associated with the development of goiter. A summary of why the other choices are incorrect: A is a systemic vasculitis, B is a type of vasculitis involving the aorta and its main branches, and C is a fictional disease.
A home health nurse is caring for a child who has lyme disease. Which of the following is an appropriate action for the nurse to take
- A. Ensure the state health department has been notified
- B. Administer antitoxin
- C. Educate the family to avoid sharing personal belongings
- D. Assess for skin necrosis
Correct Answer: B
Rationale: The correct answer is B: Administer antitoxin. Lyme disease is caused by a bacterium, not a toxin, so administering antitoxin is not appropriate. Option A is incorrect because notifying the state health department is not a direct action for the nurse to take in caring for the child. Option C is incorrect as educating the family to avoid sharing personal belongings is a preventive measure but not a direct action for the child's care. Option D is incorrect as skin necrosis is not a typical manifestation of Lyme disease. Administering appropriate antibiotics to treat the bacterial infection is the most appropriate action for the nurse to take in caring for the child with Lyme disease.
A nurse is caring for a baby that may have sickle cell disease. Which of the following tests should be performed to distinguish sickle cell trait from sickle cell disease?
- A. Hemoglobin electrophoresis
- B. Sickle solubility test
- C. Complete Blood Count (CBC)
- D. International Normalized Ratio (INR)
Correct Answer: A
Rationale: The correct answer is A: Hemoglobin electrophoresis. This test is used to distinguish sickle cell trait from sickle cell disease by separating different types of hemoglobin based on their electrical charge. Sickle cell trait will show a different hemoglobin pattern compared to sickle cell disease.
B: Sickle solubility test is not specific enough to differentiate between sickle cell trait and disease.
C: Complete Blood Count (CBC) provides general information about blood cells but does not specifically differentiate between sickle cell trait and disease.
D: International Normalized Ratio (INR) is used to monitor blood clotting and is not relevant for distinguishing sickle cell trait from disease.
A nurse is instructing a school-age child who has asthma about the use of a peak expiratory flow meter. Which of the following instructions should the nurse include?
- A. Place tongue on the mouthpiece of the meter.
- B. Maintain a semi-Fowler's position during testing.
- C. Record the average of the readings.
- D. Blow into the meter as hard and quickly as possible.
Correct Answer: D
Rationale: The correct answer is D: Blow into the meter as hard and quickly as possible. This instruction is correct because when using a peak expiratory flow meter, the individual needs to blow out as forcefully as possible to get an accurate reading of their peak expiratory flow rate. This helps in assessing the severity of asthma symptoms and monitoring the effectiveness of treatment.
A: Placing the tongue on the mouthpiece is incorrect as it may interfere with the airflow and affect the accuracy of the reading.
B: Maintaining a semi-Fowler's position is not necessary for using a peak flow meter.
C: Recording the average of the readings is not typically done with peak flow meters as the focus is on the individual's peak expiratory flow rate.
E, F, G: No other choices were provided.
In summary, blowing into the meter as hard and quickly as possible is the correct instruction for using a peak expiratory flow meter, as it ensures an accurate measurement of peak expir
Congenital heart defects are classified as all of the following? (Select all that apply)
- A. Mixed defects
- B. Obstruction defects
- C. Decreased pulmonary blood flow
- D. Acquired defects
Correct Answer: A,B,C
Rationale: Congenital heart defects can be classified based on pathophysiology. A: Mixed defects involve combination of two types of abnormalities, B: Obstruction defects involve narrowing/blockage in blood flow, and C: Decreased pulmonary blood flow includes defects leading to decreased blood flow to lungs. D: Acquired defects result from external factors and not present at birth. E, F, G are not applicable as no information is provided. Thus, A, B, C are correct based on classification of congenital heart defects.