Nokea
A child is admitted to the hospital with a diagnosis of nephrotic syndrome. The nurse expects to note documentation of which manifestation in the medical record? Select all that apply.
- A. Edema
- B. Proteinuria
- C. Hypertension
- D. Abdominal pain
- E. Increased weight
- F. Hypoalbuminemia
Correct Answer: A,B,D,E,F
Rationale: Nephrotic syndrome refers to a kidney disorder characterized by edema, proteinuria, and hypoalbuminemia. The child also experiences anorexia, fatigue, abdominal pain, respiratory infection, and increased weight. The child's blood pressure is usually normal or slightly below normal.
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The pediatric nurse specialist teaches nursing students about mumps. Which clinical manifestation will the specialist identify as the most common complication of this disease?
- A. Pain
- B. Nuchal rigidity
- C. Impaired hearing
- D. A red swollen testicle
Correct Answer: B
Rationale: The most common complication of mumps is aseptic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. Muscular pain, parotid pain, or testicular pain may occur, but pain does not indicate a sign of a common complication. Although mumps is one of the leading causes of unilateral nerve deafness, it does not occur frequently. A red swollen testicle may be indicative of orchitis. Although this complication appears to cause most concern among parents, it is not the most common complication.
The nurse caring for a postpartum client should suspect that the client is experiencing endometritis if which is noted?
- A. Breast engorgement
- B. Elevated white blood cell count
- C. Lochia rubra on the second day postpartum
- D. Fever over 38°C (100.4°F), beginning 2 days postpartum
Correct Answer: D
Rationale: Endometritis is a common cause of postpartum infection. The presence of fever of 38°C (100.4°F) or more on 2 successive days of the first 10 postpartum days (not counting the first 24 hours after birth) is indicative of a postpartum infection. Breast engorgement is a normal response in the postpartum period and is not associated with endometritis. The white blood cell count of a postpartum woman is normally elevated; thus, this method of detecting infection is not of great value in the puerperium. Lochia rubra on the second day postpartum is a normal finding.
The nurse who practices culturally sensitive nursing care incorporates which concepts into client care? Select all that apply.
- A. The expression of pain is affected by learned behaviors.
- B. Physiologically, all individuals experience pain in a similar manner.
- C. Ethnic culture has an effect on the physiological response to pain medications.
- D. Clients should be assessed for pain regardless of a lack of overt symptomatology.
- E. The use of a standardized pain assessment tool ensures unbiased pain assessment.
Correct Answer: A,C,D
Rationale: Pain and its expression are often affected by an individual's ethnic culture in ways that include learned means of pain expression, the physiological response to pain medications, and attitudes regarding acceptable ways of dealing with pain. Physiologically not all individuals, even those of the same ethnic culture, will respond to pain in a similar manner, and so a standardized pain assessment tool is not effective in measuring pain in all clients.
The nurse is teaching a pregnant client about prenatal nutritional needs. The nurse should include which information in the client's teaching plan?
- A. All mothers are at high risk for nutritional deficiencies.
- B. Calcium intake is not necessary until the third trimester.
- C. Iron supplements are not necessary unless the mother has iron deficiency anemia.
- D. The nutritional status of the mother significantly influences fetal growth and development.
Correct Answer: D
Rationale: Poor nutrition during pregnancy can negatively influence fetal growth and development. Although pregnancy poses some nutritional risk for the mother, not all clients are at high risk. Calcium intake is critical during the third trimester but must be increased from the onset of pregnancy. Intake of dietary iron is insufficient for the majority of pregnant women, and iron supplements are routinely prescribed.
After assessment and diagnostic evaluation, it has been determined that the client has a diagnosis of Lyme disease, stage II. The nurse assesses the client for which manifestation that is most indicative of this stage?
- A. Lethargy
- B. Headache
- C. Erythematous rash
- D. Cardiac dysrhythmias
Correct Answer: D
Rationale: Stage II of Lyme disease develops within 1 to 3 months in most untreated individuals. The most serious problems in this stage include cardiac dysrhythmias, dyspnea, dizziness, and neurological disorders such as Bell's palsy and paralysis. These problems are not usually permanent. Flulike symptoms (headache and lethargy), muscle pain and stiffness, and a rash appear in stage I.