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A hospitalized child with minimal change nephrotic syndrome is receiving high doses of prednisone. Which is an appropriate nursing goal related to this?
- A. Prevent infection
- B. Stimulate appetite
- C. Detect evidence of edema
- D. Ensure compliance with prophylactic antibiotic therapy
Correct Answer: C
Rationale: Nephrotic syndrome is characterized by the presence of edema due to loss of protein in the urine. One of the nursing goals in managing a child with minimal change nephrotic syndrome receiving high doses of prednisone is to monitor for the development or worsening of edema. Detecting evidence of edema is important as it can help in assessing the effectiveness of treatment, such as monitoring the response to prednisone therapy and adjusting the treatment plan accordingly. Monitoring for edema can also help in preventing complications associated with fluid overload, such as hypertension and respiratory distress. Therefore, detecting evidence of edema is an appropriate nursing goal in this scenario.
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An appropriate nursing action to include in the care of an infant with congenital heart disease who has been admitted with heart failure is:
- A. Positioning flat on the back
- B. Encouraging nutritional fluids
- C. Offering small frequent feedings
- D. Measuring the head circumference
Correct Answer: C
Rationale: Infants with congenital heart disease who have been admitted with heart failure may have difficulty feeding due to increased work of breathing and poor energy reserves. Offering small, frequent feedings can help prevent fatigue and provide adequate nutrition to support the infant's growth and recovery. It also helps to prevent overloading the heart with a large volume of fluids at once. This approach allows the infant to receive enough calories while reducing the risk of aspiration and conserving energy for feeding and breathing. Positioning the infant flat on the back may worsen respiratory distress, encouraging nutritional fluids alone may not address the feeding challenges faced by the infant, and measuring the head circumference is important for growth monitoring but may not be the priority when managing heart failure in this case.
Which of the ff. nursing interventions will help prevent complications in the patient with Bell's Palsy?
- A. Megavitamin therapy
- B. Application of ice to the affected area
- C. Elastic bandages
- D. Lubricating eye drops
Correct Answer: D
Rationale: Bell's Palsy is a condition that affects the facial nerve, leading to weakness or paralysis of the facial muscles. One common complication of Bell's Palsy is the inability to fully close the affected eye, which can result in corneal exposure and dryness. Lubricating eye drops help prevent dryness and protect the cornea from damage due to inadequate eye closure. Using lubricating eye drops regularly can help maintain the eye's moisture and prevent potential complications such as corneal abrasions and infections, which are common in patients with Bell's Palsy. Megavitamin therapy, application of ice, and elastic bandages are not typically indicated for preventing complications in patients with Bell's Palsy.
The age at which the infant can see an object, grasp it, and bring it to the mouth is
- A. 4 months
- B. 5 months
- C. 6 months
- D. 7 months
Correct Answer: A
Rationale: This milestone is typically achieved around 4 months.
The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
- A. "Client will lose 2lb per week on a calorie-restricted diet."
- B. "Client will exhibit no signs or symptoms of aspiration."
- C. "Client will exhibit bowel and bladder continence."
- D. "Client will exhibit alertness and orientation to person, place, and time."
Correct Answer: B
Rationale: Polymyositis is a condition that involves inflammation of the muscles, including the muscles involved in swallowing (dysphagia) and breathing. This can lead to a higher risk of aspiration, where food or fluids go into the airway instead of the esophagus. Therefore, monitoring for signs and symptoms of aspiration and ensuring the client exhibits no signs of aspiration are crucial in the care of a client with polymyositis. The other options are not directly related to the potential problems associated with polymyositis and are more general aspects of nursing care.
A patient is hospitalized following a stroke. Three days after admission, the patient is able to converse clearly with the nurse during the morning assessment. Early in the afternoon, the patient's daughter runs out of the room and says, "My mother can't talk. Somebody help!" Which response by the nurse is best?
- A. Explain to the daughter that this is not uncommon, esp. in the afternoon when the patient is tired from the morning care activities.
- B. Do a quick assessment to confirm the change in the patient's status, then notify the RN or physician.
- C. Call the speech therapist to come and to do a comprehensive speech assessment.
- D. Show the daughter how to do the speech exercises with her mother that were provided by the therapist
Correct Answer: B
Rationale: The best response by the nurse in this situation would be to do a quick assessment to confirm the change in the patient's status and then notify the registered nurse (RN) or physician. It is essential for the healthcare team to promptly assess and address any sudden changes in a stroke patient's condition, such as the sudden inability to speak. This could indicate a serious issue that requires immediate attention and intervention. By quickly assessing the patient's status and notifying the appropriate healthcare provider, the nurse can ensure that the patient receives the necessary care and interventions in a timely manner.