Nokea
A nurse is assessing a preterm newborn for the possibility of necrotizing enterocolitis (NEC). Which assessment findings should the nurse expect to find if NEC is confirmed? (Select all that apply.)
- A. Minimal gastric residual
- B. Abdominal distention
- C. Apnea
- D. Urinary output at 2 ml/kg/hr
Correct Answer: B
Rationale: Abdominal distention: NEC is characterized by abdominal distention due to gas and fluid accumulation in the intestines, leading to a bloated appearance of the abdomen.
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In preparing a preschool-aged patient for an injection, the most appropriate nursing intervention is to:
- A. allow the patient to administer an injection to a doll.
- B. arrange for the patient to watch a peer receive an injection.
- C. have the parents explain the process to the patient.
- D. suggest diversionary activities like singing.
Correct Answer: A
Rationale: Allowing the child to practice on a doll can help reduce anxiety and prepare them for the procedure.
Mrs. Santos, a 75-year old patient with type II diabetes is in emergency department with signs of hyperglycemic, hyperosmolar nonketotic (HHNK) coma. What assessment finding should the nurse expect?
- A. Fruity odor of the breath
- B. shallow, deep respirations
- C. severe dehydration
- D. profuse sweating
Correct Answer: C
Rationale: In a patient with hyperglycemic, hyperosmolar nonketotic coma (HHNK), the high blood glucose levels lead to osmotic diuresis, causing excessive urination and subsequent dehydration. Dehydration can manifest as symptoms such as dry mucous membranes, poor skin turgor, decreased urine output, increased heart rate, and low blood pressure. Therefore, the nurse should expect to find signs of severe dehydration in a patient with HHNK coma. The other options listed are not typical assessment findings associated with HHNK coma.
Which is most important to document about immunizations in the child's health history?
- A. Dosage of immunizations received
- B. Occurrence of any reaction after an immunization
- C. The exact date the immunizations were received
- D. Practitioner who administered the immunizations
Correct Answer: C
Rationale: The most important information to document about immunizations in a child's health history is the exact date the immunizations were received. This information is crucial for tracking when the child is due for their next immunizations and to ensure they are following the recommended vaccination schedule. The dosage of immunizations received, occurrence of any reaction after an immunization, and the practitioner who administered the immunizations are also important details to document but the most critical one is the date to accurately maintain the vaccination records and plan future immunization appointments.
A 10-mo-old boy has a left suprarenal mass. Surgery is accomplished with complete removal of the mass as well as the non-adherent lymph nodes; surgical biopsies are taken during surgery. The histology reveals poorly differentiated neuroblastoma with microscopic ipsilateral lymph nodes involvement. The contralateral lymph nodes are negative. Of the following, the BEST therapeutic approach for this infant is
- A. chemotherapy
- B. radiotherapy
- C. concomitant chemo-radiotherapy
- D. chemotherapy followed by radiotherapy
Correct Answer: A
Rationale: Complete resection with microscopic residual disease typically warrants adjuvant chemotherapy.
One nursing diagnosis for JRA is impaired physical mobility. Select all nursing interventions that apply.
- A. Give pain medication prior to ambulation.
- B. Assist with range-of-motion activities.
- C. Encourage the child to eat a high-fat diet.
- D. Provide oxygen as necessary.
Correct Answer: A
Rationale: Giving pain medication prior to ambulation can help alleviate discomfort and improve the child's ability to perform physical activities, thus promoting mobility.