Nokea
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.
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A child being administered a new medication displays signs of an adverse drug reaction. The nurse would expect treatment of the reaction to include (Select all that apply):
- A. Administering antibiotics
- B. Discontinuing the drug
- C. Administering antihistamines
- D. Administering corticosteroids
Correct Answer: B,C,D
Rationale: The correct answer is B, C, and D. Discontinuing the drug is essential to stop the adverse reaction. Administering antihistamines helps manage symptoms like itching and hives. Corticosteroids can reduce inflammation and allergic responses caused by the reaction. Antibiotics (choice A) are not indicated unless there is a specific infection requiring treatment. No other choices were provided, but it's crucial to focus on stopping the offending drug, managing symptoms, and addressing inflammation in the case of an adverse drug reaction.
A nurse is providing discharge teaching to the parents of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include?
- A. Perform chest percussion and postural drainage at least twice daily.
- B. Restrict intake of foods that contain gluten.
- C. Administer pancreatic enzymes on an empty stomach.
- D. Use a nebulizer to administer a bronchodilator following airway clearance therapy.
Correct Answer: A
Rationale: The correct answer is A: Perform chest percussion and postural drainage at least twice daily. This is crucial in managing cystic fibrosis as it helps to loosen and clear mucus from the lungs. Chest percussion and postural drainage can improve lung function and reduce the risk of respiratory infections. Restricting intake of foods that contain gluten (B) is not necessary for cystic fibrosis. Administering pancreatic enzymes on an empty stomach (C) is important but not the priority in this case. Using a nebulizer to administer a bronchodilator following airway clearance therapy (D) is helpful but not as essential as chest percussion and postural drainage.
The doctor has ordered Synthroid 75 mcg oral daily. The available Synthroid is 0.15 mg tablets. How many tablets will the nurse administer?
- A. 1 tablet
- B. 0.5 tablet
- C. 2 tablets
- D. 1.5 tablets
Correct Answer: B
Rationale: The correct answer is B: 0.5 tablet. To determine the number of tablets needed, convert 75 mcg to mg by dividing by 1000 (75 mcg = 0.075 mg). Then, divide the prescribed dose (0.075 mg) by the tablet strength (0.15 mg) to find the number of tablets needed (0.075 mg / 0.15 mg = 0.5 tablet). This calculation ensures the patient receives the correct dosage. Choice A is incorrect as it does not account for the tablet strength. Choices C and D are incorrect as they result in a higher dose than prescribed.
The expected finding of Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) include:
- A. Low urine output & increased levels of antidiuretic hormone
- B. Low urine output & decreased levels of antidiuretic hormone
- C. Increased urine output & decreased levels of antidiuretic hormone
- D. Increased urine output & increased levels of antidiuretic hormone
Correct Answer: A
Rationale: The correct answer is A: Low urine output & increased levels of antidiuretic hormone. In SIADH, there is an excessive release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia. This results in low urine output as the body retains water. Increased levels of ADH cause the kidneys to reabsorb more water, further contributing to low urine output. The other choices are incorrect because in SIADH, urine output is typically low, and ADH levels are elevated due to the dysregulation of the feedback mechanism that controls ADH release. Increased urine output and decreased levels of ADH (choice C) would be more indicative of diabetes insipidus, a condition characterized by decreased ADH production or kidney insensitivity to ADH.
When instructing the parents of a toddler with iron deficiency anemia about the importance of increasing iron in the toddler's diet, which of the following foods should the nurse instruct the parents to include in the toddler's diet?
- A. Pasta
- B. Vitamin D milk
- C. Dried fruits
- D. Green leafy vegetables
Correct Answer: C
Rationale: The correct answer is C: Dried fruits. Dried fruits are a good source of iron, which is essential for treating iron deficiency anemia in toddlers. They provide a concentrated amount of iron in a small serving size, making them convenient for toddlers. Pasta (A) does not contain significant amounts of iron. Vitamin D milk (B) is important for bone health but does not provide a substantial amount of iron. Green leafy vegetables (D) are a good source of iron, but they may be harder for toddlers to eat compared to dried fruits.