Nokea
a hospitalized child with nephrosis is receiving high doses of prednisone. which of the following is an appropriate nursing goal related to this?
- A. prevent infection.
- B. stimulate appetite.
- C. detect evidence of edema.
- D. assist in raising osmotic pressure.
Correct Answer: A
Rationale: High doses of prednisone suppress the immune system, putting the hospitalized child at an increased risk for infections. Therefore, an appropriate nursing goal related to this situation would be to prevent infection by implementing measures such as hand hygiene, maintaining a clean environment, and monitoring for signs and symptoms of infection. It is crucial to protect the child from acquiring additional illnesses while undergoing treatment for nephrosis.
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Which of the ff is an assessment finding in a client with bonchiectasis?
- A. Same amount of sputum at all stages of the disease
- B. Non productive cough
- C. Expectoration of small amounts of sputum
- D. Worsening cough with position changes
Correct Answer: C
Rationale: Bronchiectasis is a condition characterized by the abnormal widening and thickening of the bronchial tubes, leading to a build-up of mucus. One of the common assessment findings in clients with bronchiectasis is the expectoration of small amounts of sputum. This is due to the increased mucus production and impaired clearance from the airways. The sputum may be foul-smelling and may contain pus or blood due to chronic infection and inflammation in the bronchial tubes.
A 46 y.o. woman is admitted to the rehabilitation unit with left-sided hemiparesis resulting from a subarachnoid hemorrhage. She is not oriented to her surroundings or situation, but she does recognize her family. On admission, she tells her nurse that she can walk to the bathroom without assistance. Which of the ff. responses by the nurse is best?
- A. Allow her to ambulate unassisted, to encourage positive self-esteem.
- B. Ask her to demonstrate her ability to ambulate.
- C. Explain that someone will assist her as long as she is in the rehabilitation facility.
- D. Ask another staff member to help ambulate the patient the first time.
Correct Answer: C
Rationale: The best response by the nurse is to explain that someone will assist the patient as long as she is in the rehabilitation facility. This is important for ensuring the safety of the patient, especially considering her condition with left-sided hemiparesis resulting from a subarachnoid hemorrhage. While encouraging independence is important in rehabilitation, it should not compromise the patient's safety. The nurse should prioritize the patient's well-being and provide necessary assistance to prevent any potential falls or injuries during ambulation.aising the risk of falling or getting injured.
A client has type1 diabetes. Her husband finds her unconscious at home and administers glucagons, 0.5 mg S.C. She awakens in 5 minutes .Why her husband offer a complex carbohydrate snack to her as soon as possible?
- A. To decrease the possibility of nausea and vomiting
- B. To restore liver glycogen and prevent secondary hypoglycemia
- C. To stimulate her appetite
- D. To decrease the amount of glycogen in her system
Correct Answer: B
Rationale: Providing a complex carbohydrate snack to the client after she has been treated with glucagon is important to restore liver glycogen and prevent secondary hypoglycemia. Glucagon works by stimulating the liver to release stored glucose, which quickly raises blood sugar levels. However, this can deplete the liver's glycogen stores, making the client susceptible to experiencing hypoglycemia again if additional glucose is not consumed. Offering a complex carbohydrate snack will help replenish the liver's glycogen stores and sustain blood sugar levels to prevent a recurrence of hypoglycemia.
The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will be able to heat the baby's formula faster. What should the nurse recommend?
- A. Never heat a bottle in a microwave oven.
- B. Heat only 10 ounces or more.
- C. Always leave bottle top uncovered to allow heat to escape.
- D. Shake bottle vigorously for at least 30 seconds after heating.
Correct Answer: A
Rationale: The nurse should recommend never heating a bottle in a microwave oven. Microwaves do not heat liquids evenly, and there is a risk of creating hot spots in the formula, which can burn the baby's mouth and throat. It is safer to heat the formula by placing the bottle in warm water or using a bottle warmer to ensure uniform heating throughout.
A total thyroidectomy is ordered following discovery of a cold nodule. In this case of hyperthyroidism versus malignancy, the nurse anticipates that the patient will have:
- A. A complete thyroidectomy also
- B. a partial thyroidectomy (approximately one-half of the thyroid is removed)
- C. a partial thyroidectomy (approximately five-sixths of the thyroid is removed)
- D. administration of thyroid medication
Correct Answer: A
Rationale: A total thyroidectomy is the removal of the entire thyroid gland. In the case of a cold nodule, which may indicate malignancy, a total thyroidectomy is usually performed to ensure complete removal of the potentially cancerous tissue. Hyperthyroidism, on the other hand, can often be managed with medication or a partial thyroidectomy, depending on the underlying condition. In this scenario, the presence of a cold nodule suggests a higher likelihood of malignancy, hence the need for a total thyroidectomy.