Nokea
A mother has come to the pediatric clinic concerned about the recent outbreak of West Nile Virus. The ages of her children are 5, 7, and 10. The mother has asked the nurse what she can do to prevent her children from contracting this illness. Which piece of information is best to provide the mother with?
- A. The children should wear long sleeves and long pants while outside.
- B. Apply insect repellant containing DEET when the children are outside.
- C. Remove standing water from the property.
- D. All of the above.
Correct Answer: D
Rationale: It is recommended that the children wear insect repellant containing DEET and long-sleeve shirts and long pants when they are outside. Removing standing water can help decrease the number of breeding mosquitoes.
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Fat emulsions are frequently administered as a part of total parenteral nutrition. Which statement is true regarding fat emulsions?
- A. They have a high energy-to-fluid-volume ratio.
- B. Even though hypertonic, they are well tolerated.
- C. They are a basic solution secondary to the addition of sodium hydroxide (NaOH).
- D. The pH is alkaline, making them compatible with most medications.
Correct Answer: A
Rationale: They have a high energy-to-fluid-volume ratio. Fat emulsions are formulated in 10%, 20%, and 30% solutions and supply 1.1, 2, and 3 kilocalories respectively for each milliliter. A milliliter of 5% dextrose only supplies 0.17 kilocalories. Choices 2, 3, and 4 are incorrect because fat emulsions are essentially pH neutral and isotonic.
If your patient is acutely psychotic, which of the following independent nursing interventions would not be appropriate?
- A. Conveying calmness with one on one interaction
- B. Recognizing and dealing with your own feelings to prevent escalation of the patient's anxiety level
- C. Encourage client participation in group therapy
- D. Listen and identify causes of their behavior
Correct Answer: C
Rationale: Acutely psychotic patients will disrupt group activities.
A patient has suffered a left CVA and has developed severe hemiparesis resulting in a loss of mobility. The nurse notices on assessment that an area over the patient's left elbow appears as non-blanchable erythema and the skin is intact. The nurse should score the patient as having which of the following?
- A. Stage I pressure ulcer
- B. Stage II pressure ulcer
- C. Stage III pressure ulcer
- D. Stage IV pressure ulcer
Correct Answer: A
Rationale: Erythema with the skin intact can indicate a Stage I pressure ulcer.
Which of the following home-care strategies is most likely to negatively impact the body image of a client with Cushing's syndrome?
- A. providing safety measures to prevent falls
- B. taking medications as prescribed
- C. wearing a medical ID indicating Cushing's syndrome
- D. having regular health assessments
Correct Answer: C
Rationale: All of the strategies listed are included in home care for the client with Cushing's syndrome. Choice 3 is the best answer because wearing a medical ID is a visible sign that something is wrong and a constant reminder to the client that he or she has a loss of body function. Choice 1 might enhance body image because it prevents falls that could cause further injury and debilitation. Taking medications as prescribed should enhance body image because it decreases the symptoms present. Having regular health assessments indicates an enhanced body image because it signals the desire to take care of the body and keep it at its best.
A client asks the nurse if all donor blood products are cross-matched with the recipient to prevent a transfusion reaction. Which of the following always requires cross-matching?
- A. Packed red blood cells
- B. Platelets
- C. Plasma
- D. Granulocytes
Correct Answer: A
Rationale: Packed red blood cells require cross-matching due to their antigens and antibodies, unlike platelets, plasma, or granulocytes, which do not contain red cells.