Nokea
A nurse is assessing a client with HIV who has been admitted with pneumonia. In assessing the client, which of the following observations takes immediate priority?
- A. Oral temperature of $37.2^{\circ} \mathrm{C}\left(99^{\circ} \mathrm{F}\right)$
- B. Tachypnea and restlessness
- C. Frequent loose stools
- D. Weight loss of $0.45 \mathrm{~kg}$ ( $1 \mathrm{lb}$.) since yesterday
Correct Answer: B
Rationale: The correct answer is B, tachypnea and restlessness. This is the immediate priority because it indicates respiratory distress, a potentially life-threatening complication in a client with pneumonia and HIV. Tachypnea suggests inadequate oxygenation, while restlessness may indicate hypoxia. Prompt intervention is crucial to prevent respiratory failure.
Choice A, oral temperature, is important but not as urgent as addressing respiratory distress. Choice C, frequent loose stools, could be a concern but is not an immediate priority compared to respiratory distress. Choice D, weight loss, is relevant but does not require immediate intervention like tachypnea and restlessness.
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A child is diagnosed with rhabdomyosarcoma. Which nursing intervention is most appropriate for this child?
- A. Position the child with the head elevated.
- B. Monitor for hematuria.
- C. Demonstrate the use of a conformer.
- D. Administer oxygen.
Correct Answer: B
Rationale: The correct answer is B: Monitor for hematuria. Rhabdomyosarcoma is a type of cancer that originates from muscle tissue and can potentially lead to bleeding in the urine (hematuria). Monitoring for hematuria is crucial to assess the child's condition and detect any signs of complications.
A: Positioning the child with the head elevated is not directly related to managing rhabdomyosarcoma.
C: Demonstrating the use of a conformer is not relevant to the immediate nursing care for rhabdomyosarcoma.
D: Administering oxygen may be necessary in some cases, but monitoring for hematuria is more specific and directly related to the potential complications of rhabdomyosarcoma.
What signs would you expect to see in a patient when diagnosing malaria? (Choose one)
- A. Rash
- B. Fever
- C. Chest pain
- D. Hair loss
Correct Answer: B
Rationale: The correct answer is B: Fever. In diagnosing malaria, fever is a key symptom due to the cyclic nature of the disease. Malaria typically presents with recurrent bouts of fever, which is caused by the cycle of the parasite invading and multiplying in red blood cells. The other choices (A: Rash, C: Chest pain, D: Hair loss) are not typical signs of malaria. Rash is more commonly seen in diseases like dengue fever, chest pain could be indicative of other conditions like pneumonia or heart issues, and hair loss is not a characteristic symptom of malaria. Therefore, fever is the most characteristic and essential sign to consider when diagnosing malaria.
The nurse is educating a new mom on natural versus acquired immunity. What is an example of a statement by the mother that shows the nurse that she understood the teaching?
- A. Natural immunity develops when my baby receives immunizations.
- B. Natural immunity is only present before the baby is born.
- C. Acquired immunity develops after birth.
- D. Acquired immunity develops only after exposure to an illness.
Correct Answer: C
Rationale: The correct answer is C: Acquired immunity develops after birth. This statement is correct because acquired immunity refers to the immunity that develops after exposure to antigens, such as through infection or vaccination. It involves the immune system recognizing and remembering specific pathogens to provide protection in the future. This shows the mother understands the difference between natural (innate) immunity, which is present at birth, and acquired immunity, which develops over time.
Incorrect choices:
A: Natural immunity develops when my baby receives immunizations - This is incorrect as immunizations are a form of acquired immunity.
B: Natural immunity is only present before the baby is born - This is incorrect as natural immunity is present at birth and acquired immunity develops after birth.
D: Acquired immunity develops only after exposure to an illness - This is incorrect as acquired immunity can also develop through vaccinations, not just exposure to illnesses.
Patient with weakness, tingling, macrocytic anemia. Not a factor?
- A. Chronic atrophic gastritis
- B. Ileal resection
- C. Tapeworm infestation
- D. Alcoholism
Correct Answer: A
Rationale: The correct answer is A: Chronic atrophic gastritis. This condition leads to vitamin B12 deficiency, causing macrocytic anemia, weakness, and tingling. Chronic atrophic gastritis affects the stomach's ability to produce intrinsic factor needed for B12 absorption. Ileal resection impairs B12 absorption, tapeworm infestation competes for B12, and alcoholism can lead to poor diet and malabsorption, all contributing to macrocytic anemia.
Nursing care of the child with Kawasaki disease is challenging because of:
- A. The child’s irritability.
- B. Predictable disease course.
- C. Complex antibiotic therapy.
- D. The child’s ongoing requests for food.
Correct Answer: A
Rationale: The correct answer is A because Kawasaki disease is characterized by high fever, irritability, and mucous membrane changes. The child's irritability can make nursing care challenging due to difficulties in assessing and managing their symptoms and needs effectively. The other choices are incorrect because: B - Kawasaki disease has an unpredictable course with potential complications; C - Antibiotics are not the primary treatment for Kawasaki disease; D - Requests for food are not typically a significant challenge in caring for a child with this condition. In summary, the correct answer highlights the primary symptom that can complicate nursing care, while the other choices are not directly related to the challenges of managing Kawasaki disease.