Nokea
A mother brings her 3-week-old infant to the clinic because the baby vomits after eating and always seems hungry. Further assessment indicates that the infant's vomiting is projectile, and the child seems listless. Which additional assessment finding indicates the possibility of a life-threatening complication?
- A. Irregular palpable pulse
- B. Hyperactive bowel sounds
- C. Underweight for age
- D. Crying without tears
Correct Answer: D
Rationale: In this scenario, the infant presenting with vomiting, lethargy, and projectile vomiting indicates a potential serious condition. Crying without tears is a sign of dehydration, a critical condition that can lead to life-threatening complications in infants. Dehydration can rapidly worsen an infant's condition, making prompt intervention crucial to prevent further complications.
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A child with sickle cell anemia is being treated for a vaso-occlusive crisis. Which intervention should the practical nurse (PN) implement?
- A. Apply cold packs to painful areas.
- B. Encourage increased fluid intake.
- C. Administer high doses of vitamin C.
- D. Provide low-calorie meals.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
An adolescent female who is leaning forward with her hands on her knees to breathe tells the practical nurse that she has been using triamcinolone (Azmacort) inhalation aerosol before coming to the clinic. Which action should the PN implement?
- A. Obtain vital signs and assess breath sounds for wheezing.
- B. Collect a blood sample for white blood cell count.
- C. Give the client a nebulizer breathing treatment.
- D. Administer another dose of Azmacort.
Correct Answer: A
Rationale: When a patient presents with breathing difficulties, the first action should be to assess vital signs and breath sounds to evaluate the severity of the condition. This assessment will provide crucial information to determine the appropriate course of action and treatment. Collecting a blood sample for a white blood cell count, giving a nebulizer treatment, or administering another dose of Azmacort would not be the initial priority in this situation.
What instructions should the nurse provide to the parents about the treatment of head lice in a 3-year-old boy who has been confirmed to have head lice?
- A. Wash the child's bed linens and clothing in hot soapy water.
- B. Dispose of the child's brushes, combs, and other hair accessories.
- C. Rewash the child's hair following a 24-hour isolation period.
- D. Take the child to a hair salon for a shampoo and shorter haircut.
Correct Answer: A
Rationale: The correct instruction for the nurse to provide to the parents is to wash the child's bed linens and clothing in hot soapy water. This is essential to eliminate head lice as they can survive on bedding and clothing. It is also important to wash any other items that the child may have used or come into contact with, such as brushes and combs, to prevent reinfestation. Rewashing the child's hair following an isolation period is not necessary, and taking the child to a hair salon for a shampoo and shorter haircut is not a recommended treatment for head lice.
A 7-year-old child with a history of asthma is brought to the emergency department with an acute asthma exacerbation. The child is wheezing and using accessory muscles to breathe. What is the nurse's priority intervention?
- A. Administer a nebulized bronchodilator
- B. Obtain an arterial blood gas
- C. Start the child on oxygen therapy
- D. Notify the healthcare provider
Correct Answer: A
Rationale: In a 7-year-old child with an acute asthma exacerbation showing signs of wheezing and increased work of breathing, the priority intervention for the nurse is to administer a nebulized bronchodilator immediately. Bronchodilators help dilate the airways, relieve bronchospasm, and improve breathing, which is crucial in managing an acute asthma attack and preventing further respiratory distress.
A 14-year-old client with type 1 diabetes is participating in a school sports event. The nurse provides education to the client about managing blood glucose levels during physical activity. Which statement by the client indicates a need for further teaching?
- A. I should check my blood sugar before and after exercise
- B. I need to eat a snack before I start playing
- C. If my blood sugar is high, I should skip my insulin dose before exercise
- D. I should carry a fast-acting carbohydrate with me during sports
Correct Answer: C
Rationale: The correct answer is C. Skipping insulin dose when blood sugar is high before exercise can be harmful. It is essential to manage blood glucose levels carefully during physical activity, which may require adjustments to insulin doses but skipping doses is not recommended. It is crucial to maintain blood sugar levels within the target range to prevent complications during exercise.