Nokea
A child is admitted to the pediatric unit with a diagnosis of acute gastroenteritis. The nurse monitors the child for signs of hypovolemic shock as a result of fluid and electrolyte losses that have occurred in the child. Which finding would indicate the presence of compensated shock?
- A. Bradycardia
- B. Hypotension
- C. Profuse diarrhea
- D. Capillary refill time greater than 2 seconds
Correct Answer: D
Rationale: Shock may be classified as compensated or decompensated. In compensated shock, the child becomes tachycardic in an effort to increase the cardiac output. The blood pressure remains normal. The capillary refill time may be prolonged and more than 2 seconds, and the child may become irritable as a result of increasing hypoxia. The most prevalent cause of hypovolemic shock is fluid and electrolyte losses associated with gastroenteritis. Diarrhea is not a sign of shock; rather, it is a cause of the fluid and electrolyte imbalance.
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A home care nurse is assessing a client who is prescribed prazosin. Which statement by the client would support the need for further teaching regarding medication compliance?
- A. If I feel dizzy, I'll skip my dose for a few days.
- B. I can't see the numbers on the label to know how much salt is in the food.
- C. I understand why I have to keep taking the pills even when my blood pressure is normal.
- D. If I have a cold, I shouldn't take any over-the-counter remedies without consulting my doctor.
Correct Answer: A
Rationale: Prazosin is used to treat hypertension. The side effects of prazosin are dizziness and impotence. The client needs to be instructed to call the primary health care provider if these side effects occur. Holding (skipping) medication will cause an abrupt rise in blood pressure. Option 2 indicates difficulty taking care of oneself. The remaining options indicate client understanding regarding the medication.
A client diagnosed with a thrombotic stroke experiences periods of emotional lability. What should the nurse interpret this behavior as indicating?
- A. That the client is not adapting well to the disability
- B. That the problem is likely to get worse before it gets better
- C. That the client is experiencing the usual sequelae of a stroke
- D. That the client is experiencing the side effects of prescribed anticoagulants
Correct Answer: C
Rationale: After a thrombotic stroke, the client often experiences periods of emotional lability, which are characterized by sudden bouts of laughing or crying or by irritability, depression, confusion, or being demanding. This is a normal part of the clinical picture of the client with this health problem, although it may be difficult for health care personnel and family members to deal with it. The other options are incorrect.
A client had arterial blood gases drawn. The results are a pH of 7.34, a partial pressure of carbon dioxide of 37 mm Hg (37 mm Hg), a partial pressure of oxygen of 79 mm Hg (79 mm Hg), and a bicarbonate level of 19 mEq/L (19 mmol/L). Which disorder should the nurse interpret that the client is experiencing?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: Metabolic acidosis occurs when the pH falls to less than 7.35 and the bicarbonate level falls to less than 22 mEq/L (22 mmol/L). With metabolic alkalosis, the pH rises to more than 7.45 and the bicarbonate level rises to more than 27 mEq/L (27 mmol/L). With respiratory acidosis, the pH drops to less than 7.35 and the carbon dioxide level rises to more than 45 mm Hg. With respiratory alkalosis, the pH rises to more than 7.45 and the carbon dioxide level falls to less than 35 mm Hg.
The nurse performs an assessment on a client with a history of heart failure who has been taking diuretics on a long-term basis. The nurse reviews the medication record, knowing that which medication, if prescribed for this client, would place the client at risk for hypokalemia?
- A. Bumetanide
- B. Triamterene
- C. Spironolactone
- D. Hydrochlorothiazide
Correct Answer: A
Rationale: Bumetanide is a loop diuretic. The client on this medication would be at risk for hypokalemia. Triamterene, spironolactone, and hydrochlorothiazide are potassium-retaining diuretics.
The mother explains that after meals her infant has been vomiting, and now it is becoming more frequent and forceful. During the assessment, the nurse notes visible peristaltic waves moving from left to right across the infant's abdomen. On the basis of these findings, which condition should the nurse suspect?
- A. Colic
- B. Intussusception
- C. Congenital megacolon
- D. Hypertrophic pyloric stenosis
Correct Answer: D
Rationale: In pyloric stenosis, the vomitus contains sour, undigested food but no bile, the child is constipated, and visible peristaltic waves move from left to right across the abdomen. A movable, palpable, firm, olive-shaped mass in the right upper quadrant may be noted. Crying during the evening hours, appearing to be in pain, but eating well and gaining weight are clinical manifestations of colic. An infant who suddenly becomes pale, cries out, and draws the legs up to the chest is demonstrating physical signs of intussusception. Ribbon-like stool, bile-stained emesis, the absence of peristalsis, and abdominal distention are symptoms of congenital megacolon (Hirschsprung's disease).