Nokea
A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain?
- A. What time did he take his last medications?
- B. Has his weight changed in the last several days?
- C. Is he still able to tighten his belt buckle?
- D. How many hours did he sleep last night?
Correct Answer: B
Rationale: Weight gain is a key indicator of fluid retention in heart failure, which can exacerbate symptoms.
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Defects of complement system should be suspected in:
- A. Recurrent folliculitis
- B. Facial swelling following trauma
- C. Recurrent meningococcal infection
- D. Pneumocystis carinii pneumonia
Correct Answer: C
Rationale: Recurrent meningococcal infection: Defects in the complement system, especially the terminal complement components, increase the risk of recurrent meningococcal infections.
Concerning SLE:
- A. Antibodies against double standard RNA are a typical finding
- B. Haematoxylin bodies occur in areas of inflammation
- C. Usually progresses to renal failure within two years
- D. Alopecia is a recognised finding
Correct Answer: D
Rationale: Alopecia is a recognized clinical feature of systemic lupus erythematosus (SLE), often associated with disease activity.
Which medication should the nurse prepare for immediate administration to a child experiencing an anaphylactic reaction to a bee sting?
- A. Diphenhydramine (Benadryl)
- B. Dobutamine (Dobutarex)
- C. Epinephrine (Adrenalin)
- D. Calcium chloride (calcium chloride)
Correct Answer: C
Rationale: After the first priority of establishing an airway, administration of epinephrine is the drug of choice. Diphenhydramine, an antihistamine, is usually not used for severe reactions. Dobutamine and calcium chloride are not appropriate drugs for this type of reaction.
A wide splitting of S2 during expiration is auscultated in a 2-week-old infant.
- A. Atrial septal defect (ASD)
- B. Coarctation of the aorta (COA)
- C. Patent ductus arteriosis (PDA)
- D. Ventricular septal defect (VSD)
Correct Answer: A
Rationale: A wide splitting of S2 without becoming a single sound on expiration may indicate increased pulmonary flow, typical of atrial septal defect.
Which comment made by a parent of a 1-month-old infant would alert the nurse about the presence of a congenital heart defect?
- A. “He is always hungry.â€
- B. “He tires out during feedings.â€
- C. “He is fussy for several hours every day.â€
- D. “He sleeps all the time.â€
Correct Answer: B
Rationale: Fatigue during feeding or activity is common to most infants with congenital cardiac problems.