Nokea
A mother brings her 5-week-old infant to the health care clinic and tells the nurse that the child has been vomiting after meals. The mother reports that the vomiting is becoming more frequent and forceful. The nurse suspects pyloric stenosis and asks the mother which assessment question to elicit data specific to this condition?
- A. Are the stools ribbon-like, and is the infant eating poorly?
- B. Does the infant suddenly become pale, begin to cry, and draw the legs up to the chest?
- C. Does the vomit contain sour, undigested food without bile, and is the infant constipated?
- D. Does the infant cry loudly and continuously during the evening hours but nurses or takes formula well?
Correct Answer: C
Rationale: Vomiting undigested food that is not bile stained and constipation are classic symptoms of pyloric stenosis. Stools that are ribbon-like and a child who is eating poorly are signs of congenital megacolon (Hirschsprung's disease). An infant who suddenly becomes pale, cries out, and draws the legs up to the chest is demonstrating physical signs of intussusception. Crying during the evening hours, appearing to be in pain, eating well, and gaining weight are clinical manifestations of colic.
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Signs and symptoms of stroke may include all of the following EXCEPT:
- A. Sudden weakness or numbness of the face, arm, or leg.
- B. Sudden confusion.
- C. Sudden headache with no known cause.
- D. Hypotension.
Correct Answer: D
Rationale: Hypotension is not a typical sign or symptom of an acute stroke. The correct signs and symptoms of a stroke include sudden weakness or numbness of the face, arm, or leg, sudden confusion, and a sudden headache with no known cause. Hypotension, which refers to low blood pressure, is not a common indicator of a stroke. It is important to differentiate between hypotension and hypertension in the context of stroke symptoms, as hypertension (high blood pressure) is actually a risk factor for strokes. Sudden weakness, numbness, confusion, and headache are signs associated with a stroke due to a disruption in blood flow to the brain. Hypotension, on the other hand, primarily indicates low blood pressure and is not directly linked to the typical presentation of a stroke.
A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse?
- A. Arrange to change client care assignments
- B. Explain that this behavior is expected
- C. Discuss the appropriate use of 'time-out'
- D. Explain that the child needs extra attention
Correct Answer: B
Rationale: When encountering a 16-month-old child exhibiting fear of strangers by clinging to the parent and crying, it is essential for the nurse to explain that this behavior is expected. Fear of strangers typically emerges around 6-8 months of age and can continue into the toddler years and beyond. This behavior is a normal part of development as the child is displaying attachment and trust in familiar caregivers. Changing client care assignments, discussing 'time-out,' or suggesting the child needs extra attention are not appropriate initial actions in this situation. Changing care assignments is unnecessary and does not address the child's emotional needs. Discussing 'time-out' is not relevant as it pertains to discipline strategies for older children. Suggesting the child needs extra attention may misinterpret the situation; the child's behavior is a normal response to a new environment and does not necessarily indicate a need for additional attention.
Which pathologic condition is described as 'increased intraocular pressure of the eye'?
- A. Detached Retina
- B. Fovea Centralis
- C. Presbyopia
- D. Glaucoma
Correct Answer: D
Rationale: The correct answer is Glaucoma. Glaucoma is a condition characterized by increased intraocular pressure in the eye, which can lead to optic nerve damage, vision loss, and blindness if left untreated. Detached Retina (A), Fovea Centralis (B), and Presbyopia (C) are not conditions associated with increased intraocular pressure like Glaucoma. Detached Retina is a separation of the retina from its underlying tissue, Fovea Centralis is a part of the retina responsible for sharp central vision, and Presbyopia is an age-related condition affecting near vision due to the loss of flexibility in the eye's lens.
A 15-year-old female who ingested 15 tablets of maximum strength acetaminophen 45
minutes ago is rushed to the emergency department. Which of these orders should the
nurse do first?
- A. Gastric lavage
- B. Administer acetylcysteine (Mucomyst) orally
- C. Start an IV Dextrose 5% with 0.33% normal saline to keep the vein open
- D. Have the patient drink activated charcoal mixed with water
Correct Answer: A
Rationale: Acetaminophen overdose is extremely toxic to the liver causing
hepatotoxicity. Early symptoms of hepatic damage include nausea, vomiting,
abdominal pain, and diarrhea. If not treated immediately, hepatic necrosis occurs
and may lead to death. Removing as much of the drug as possible is the first step in
treatment for acetaminophen overdose, this is best done through gastric lavage.
Gastric lavage (irrigation) and aspiration consist of flushing the stomach with fluids
and then aspirating the fluid back out. This procedure is done in life-threatening
cases such as acetaminophen toxicity and only if less than one (1) hour has
occurred after ingestion.
What is the cause of meningitis that is fatal in half of the infected patients?
- A. Virus
- B. Bacteria
- C. Fungus
- D. Noninfectious agent
Correct Answer: B
Rationale: Bacterial meningitis is caused by bacterial pathogens such as Streptococcus pneumoniae, Haemophilus influenzae, Listeria monocytogenes, and Neisseria meningitidis. These bacteria commonly lead to acute onset meningitis, presenting with symptoms like fever, stiff neck, and altered consciousness. The statement that bacterial meningitis is fatal in about 50% of cases is accurate, making it a serious and life-threatening condition. Viruses can also cause meningitis, but they are not typically associated with the high fatality rate seen in bacterial meningitis. Fungal meningitis is less common and usually affects individuals with weakened immune systems. Noninfectious agents do not cause meningitis.