Nokea
A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child's dressing. Which of the following actions should the nurse take?
- A. Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site.
- B. Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site.
- C. Apply continuous pressure 2.5 cm (1 in) below the percutaneous skin site.
- D. Apply intermittent pressure 2.5 cm (1 in) above the percutaneous skin site.
Correct Answer: C
Rationale: Correct Answer: C
Rationale: Applying continuous pressure 2.5 cm below the percutaneous skin site will help control bleeding by promoting clot formation at the catheter insertion site. This pressure point is closer to the source of bleeding, ensuring better hemostasis and preventing further complications.
Summary:
A: Applying intermittent pressure below the site is incorrect as continuous pressure is more effective in achieving hemostasis.
B: Applying continuous pressure above the site is incorrect as it does not target the bleeding source directly.
D: Applying intermittent pressure above the site is incorrect as continuous pressure is preferred for controlling bleeding.
E, F, G: No information provided.
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The nurse caring for an adolescent patient with a diagnosis of goiter knows that goiter is most often caused by?
- A. Kawasaki's disease
- B. Takayasu Disease
- C. Matsuzaki Disease
- D. Hashimoto Disease
Correct Answer: D
Rationale: The correct answer is D: Hashimoto Disease. Goiter is most commonly caused by Hashimoto Disease, which is an autoimmune condition where the body attacks the thyroid gland, leading to inflammation and enlargement of the gland. This results in the development of a goiter. Kawasaki's disease (A), Takayasu Disease (B), and Matsuzaki Disease (C) are not typically associated with the development of goiter. A summary of why the other choices are incorrect: A is a systemic vasculitis, B is a type of vasculitis involving the aorta and its main branches, and C is a fictional disease.
Parents of a 4-year-old with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse's reply should be based on which statement?
- A. Parents can meet all the needs of their child
- B. Children need to understand the activities of their peers are too strenuous
- C. Constant parental supervision is required to avoid overexertion
- D. Children need opportunities to play with their peers to foster their growth and development
Correct Answer: D
Rationale: The correct answer is D: Children need opportunities to play with their peers to foster their growth and development. The rationale is as follows: Playing with peers is essential for a child's social, emotional, and cognitive development. It helps them learn important skills like cooperation, communication, and problem-solving. Restricting the child's play due to fear of overexertion can have negative consequences on their overall development. It is important for children to engage in age-appropriate play activities under supervision to ensure safety while promoting growth.
Now, let's analyze why the other choices are incorrect:
A: Parents can meet all the needs of their child - While parents play a crucial role in meeting a child's needs, social interaction with peers is also important for holistic development.
B: Children need to understand the activities of their peers are too strenuous - This places the burden on the child to limit their activities rather than promoting healthy play.
C: Constant parental supervision is required to avoid overexertion
Which should be the major consideration in selecting toys for a child who is cognitively impaired?
- A. Age appropriateness
- B. Ability to teach useful skills
- C. Safety
- D. Ability to provide exercise
Correct Answer: C
Rationale: The major consideration in selecting toys for a cognitively impaired child should be safety (Choice C). Safety is crucial as children with cognitive impairments may have difficulty understanding potential dangers or using toys appropriately. Age appropriateness (Choice A) is important, but safety should take precedence. Teaching useful skills (Choice B) can be beneficial but may not be the primary focus. Providing exercise (Choice D) is valuable, but ensuring safety should come first.
A nurse is caring for a newborn whose mother was taking methadone during her pregnancy, which of the following findings indicates the newborn is experiencing withdrawal?
- A. Bulging fontanels
- B. Acrocyanosis
- C. Bradycardia
- D. Hypertonicity
Correct Answer: D
Rationale: The correct answer is D: Hypertonicity. Newborns exposed to opioids in utero often exhibit symptoms of withdrawal, known as Neonatal Abstinence Syndrome (NAS). Hypertonicity, or increased muscle tone, is a common sign of NAS. This occurs due to the withdrawal effects of methadone on the central nervous system. Bulging fontanels (A) are not typically associated with NAS. Acrocyanosis (B) is a common finding in newborns and not specific to NAS. Bradycardia (C) refers to a slow heart rate and is not a typical sign of NAS.
A nurse is caring for a newborn. The client is at risk for developing ------- and --------
- A. hypoglycemia
- B. bronchopulmonary dysplasia
- C. transient tachypnea of the newborn
- D. tachycardia
Correct Answer: A,B
Rationale: The correct answer is A and B. Newborns are at risk for hypoglycemia due to immature glycogen stores and increased glucose utilization after birth. Bronchopulmonary dysplasia can occur in premature infants due to prolonged oxygen therapy and lung immaturity. Transient tachypnea of the newborn is a common self-limiting respiratory condition. Tachycardia can be a normal response to various stimuli in newborns. The other choices are not directly related to newborns' risk factors as stated in the question.