Nokea
A nurse is caring for a child with muscular dystrophy. Which of the following priority actions should the nurse include in the care of this child?
- A. Limit physical activity and plan frequent rest periods to avoid overexertion and exhaustion of muscle groups.
- B. Recommend genetic counseling for parents,male siblings and paternal uncles and their male offspring.
- C. Advise against flu and pneumococcal vaccines due to a compromised respiratory system.
- D. Have the child use an incentive spirometer and perform breathing exercises routinely.
Correct Answer: D
Rationale: The correct answer is D: Have the child use an incentive spirometer and perform breathing exercises routinely. This is the priority action because children with muscular dystrophy are at risk for respiratory complications due to weakened respiratory muscles. Using an incentive spirometer and performing breathing exercises help maintain lung function and prevent respiratory infections.
A: Limiting physical activity and planning rest periods is important, but respiratory care takes precedence in muscular dystrophy.
B: Genetic counseling is important for family planning but does not directly impact the child's care.
C: Advising against vaccines can increase the risk of infections in a child with compromised respiratory function.
E, F, G: No information provided.
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A woman in the transition stage of labor is using paced breathing to relieve pain. She complains of blurred vision, numbness, and tingling of her hands and mouth. Which condition is indicated by these signs and symptoms?
- A. Anoxia
- B. Hyperventilation
- C. Anxiety
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Hyperventilation. The symptoms of blurred vision, numbness, and tingling in the hands and mouth are indicative of hyperventilation. During paced breathing, if the woman breathes too quickly or deeply, it can lead to a decrease in carbon dioxide levels in the blood, causing these symptoms. To address this, the woman should be guided to slow down her breathing and breathe into a paper bag to rebreathe some carbon dioxide. Anoxia (A) is a severe lack of oxygen, which would present with different symptoms. Anxiety (C) may cause similar symptoms but is not the primary issue here. Hypertension (D) does not typically lead to these specific symptoms.
A client delivered two days ago and is suspected of having postpartum 'blues.' Which symptoms confirm the diagnosis?
- A. Uncontrollable crying and insecurity
- B. Depression and suicidal thoughts
- C. Sense of the inability to care for the family and extreme anxiety
- D. Nausea and vomiting
Correct Answer: A
Rationale: The correct answer is A because uncontrollable crying and insecurity are classic symptoms of postpartum blues, also known as baby blues. This condition is characterized by mood swings, tearfulness, and feelings of vulnerability. Choices B, C, and D are incorrect as they suggest more severe symptoms associated with postpartum depression or other mental health disorders, which require immediate intervention. Nausea and vomiting (choice D) are not typically associated with postpartum blues. It is essential to differentiate between postpartum blues and more serious conditions to provide appropriate support and treatment to the client.
A nurse smells an odor identified as marijuana coming from a room. Which of the following client findings would confirm inhalation of the substance?
- A. Poor coordination, red eyes, and euphoria
- B. Slurred speech, confusion, and combativeness
- C. Loss of consciousness, respiratory depression, and coma
- D. Hypertension, tachycardia, and hyperflexia
Correct Answer: A
Rationale: The correct answer is A because poor coordination, red eyes, and euphoria are classic signs of marijuana inhalation. Poor coordination is a common effect due to impairment of motor skills. Red eyes result from vasodilation caused by marijuana. Euphoria is a psychological effect of the drug. Slurred speech, confusion, and combativeness (Option B) are more indicative of alcohol or sedative use. Loss of consciousness, respiratory depression, and coma (Option C) are severe symptoms more likely associated with opioid or sedative overdose. Hypertension, tachycardia, and hyperflexia (Option D) are not typically seen with marijuana use; they are more consistent with stimulant use.
An hour after delivery, the nurse instills erythromycin (Ilotycin) ointment into the eyes of a newborn. The main objective of the treatment is to prevent infection caused by which organism?
- A. Rubella
- B. Gonorrhea
- C. Syphilis
- D. Human immunodeficiency virus (HIV)
Correct Answer: B
Rationale: The correct answer is B: Gonorrhea. Erythromycin ointment is used to prevent ophthalmia neonatorum, a purulent conjunctivitis that can result from gonorrhea infection in newborns during passage through the birth canal. Gonorrhea is a common cause of this condition, and timely administration of erythromycin helps prevent its development. Rubella, syphilis, and HIV do not typically cause ophthalmia neonatorum, so choices A, C, and D are incorrect in this context.
A nurse is caring for a toddler who is in an oxygen tent. Which of the following actions should the nurse take in order to promote comfort while maintaining the child's safety?
- A. Give the child a stuffed animal and car with rubber wheels to play with.
- B. "Give the child a stuffed animal and car with rubber wheels to play with."'
- C. "Change the bedding and the child's clothing frequently or as often as needed."'
- D. "Tuck the bottom of the tent under the mattress on three sides,leaving one side open so the child can look out."'
Correct Answer: C
Rationale: The correct answer is C. Changing the bedding and the child's clothing frequently promotes comfort by ensuring cleanliness and preventing skin irritation. This action also maintains the child's safety by reducing the risk of infections and skin breakdown. Giving a stuffed animal and a car with rubber wheels (Choice A) may pose a choking hazard. Tucking the bottom of the tent under the mattress on three sides (Choice D) may restrict airflow and increase the risk of suffocation.