A nurse is assessing a child with kwashiorkor disease. Which assessment findings should the nurse expect?
- A. Thin wasted extremities with a prominent abdomen
- B. Constipation
- C. Elevated hemoglobin
- D. High levels of protein
Correct Answer: A
Rationale: Kwashiorkor is a form of severe acute malnutrition characterized by a deficiency in protein intake, leading to a protein-energy malnutrition. One of the hallmark signs of kwashiorkor is an enlarged, protruding abdomen due to fluid retention in the tissues (edema), giving the appearance of a swollen belly. Additionally, individuals with kwashiorkor often have thin, wasted extremities while their abdomen appears disproportionately distended. This is known as the "big belly, skinny limbs" presentation, which arises due to the imbalance of protein and energy intake. Therefore, the nurse assessing a child with kwashiorkor should expect to find thin wasted extremities with a prominent abdomen.
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What should be included in the plan of care for a preschool-age child who is admitted in a vasoocclusive sickle cell crisis (pain episode)?
- A. Pain management
- B. Administration of heparin
- C. Factor VIII replacement
- D. Electrolyte replacement
Correct Answer: A
Rationale: Pain management is a crucial component in the plan of care for a preschool-age child admitted with a vasoocclusive sickle cell crisis. Sickle cell disease causes blood vessels to become blocked, leading to ischemia and pain. Managing pain promptly and effectively is necessary to improve the child's comfort level and prevent complications. Pain management strategies typically involve the use of analgesic medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids, tailored to the child's age and weight. Additionally, non-pharmacological interventions like distraction techniques and positioning can help in reducing pain and promoting relaxation in children during a sickle cell crisis.
A 40 year old woman with aplastic anemia is prescribed estrogen with progesterone. The nurse can expect that these medications are given for which of the following reasons?
- A. To stimulate bone growth
- B. To enhance sodium and potassium
- C. To regulate fluid balance absorption
- D. To promote utilization and storage of fluids
Correct Answer: A
Rationale: Estrogen plays a crucial role in maintaining bone density and promoting bone growth in both men and women. Aplastic anemia is a condition where the bone marrow does not produce enough blood cells, leading to low blood cell counts. Estrogen therapy is often used in aplastic anemia to help stimulate bone growth and improve bone health. Additionally, estrogen can help protect against bone loss, which is important for overall bone health in individuals with this condition. Progesterone is commonly prescribed along with estrogen to provide a balanced hormonal therapy approach.
A nurse is performing a gestational age assessment on a newborn. The nurse determines that the newborn is "term" if which findings are assessed? (Select all that apply.)
- A. Posture with fully flexed arms and legs
- B. Arm recoil brisk
- C. Square window at 90 degrees
- D. Scarf sign of elbow crossing over the midline
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A patient with a brain tumor is admitted to the medical unit to begin radiation treatments. Which nursing action should take priority?
- A. Pad the patient's side rails
- B. Teach the patient what to expect during
- C. Assess the patient's pain level radiation treatments
- D. Place the patient in isolation
Correct Answer: C
Rationale: Assessing the patient's pain level should take priority in this situation because pain management is crucial for the comfort and well-being of the patient with a brain tumor undergoing radiation treatments. Pain can affect the patient's overall quality of life and participation in treatment. By promptly assessing the patient's pain level, the nurse can determine the need for appropriate pain management interventions to ensure the patient's comfort and enhance treatment outcomes. It is important to address the patient's pain to provide holistic care and improve the patient's overall experience during the treatment process.
When preparing a site for venipunctures with alcohol, how long must the area be cleaned?
- A. 5 seconds
- B. 10 seconds
- C. 30 seconds
- D. 60 seconds
Correct Answer: C
Rationale: When preparing a site for venipunctures with alcohol, it is important to clean the area for at least 30 seconds. This ensures that the alcohol thoroughly disinfects the skin and reduces the risk of introducing infections during the procedure. Cleaning the area for a full 30 seconds allows the alcohol to effectively kill any bacteria present on the skin's surface, creating a safe environment for the venipuncture to take place. Shortening the cleaning time may compromise the cleanliness of the site and increase the chances of contamination. Therefore, 30 seconds is the recommended duration for cleaning the site with alcohol before a venipuncture.