Nokea
A nurse is caring for an adolescent with a closed femur fracture who also has HIV. What type of precautions should the nurse institute?
- A. The patient should be placed on neutropenic precautions due to the risk of osteomyelitis
- B. The patient should be placed on standard precautions to diminish the risk of HIV transmission
- C. The patient should be placed on contact precautions to prevent contact with blood or bloody fluid
- D. The patient should be placed on isolation once the HIV status is suspected
Correct Answer: B
Rationale: The correct answer is B: The patient should be placed on standard precautions to diminish the risk of HIV transmission. Standard precautions are used for all patients to prevent the transmission of infection. In this case, the adolescent has a closed femur fracture and HIV, so the nurse should follow standard precautions, which include hand hygiene, wearing gloves, and using personal protective equipment as needed. Neutropenic precautions (choice A) are not necessary unless the patient has a low white blood cell count. Contact precautions (choice C) are used for specific infections that are spread by direct contact with the patient or their environment. Isolation (choice D) is not required solely based on HIV status.
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When caring for a patient with Syndrome of inappropriate Antidiuretic Hormone Secretion (SIADH), the nurse would expect her patient to exhibit the following clinical signs and symptoms (Select all that apply):
- A. Fluid retention
- B. Hypotonicity
- C. Anorexia
- D. Frequent urination
Correct Answer: A,B,C
Rationale: Step-by-step rationale:
A: Fluid retention - In SIADH, there is excessive ADH secretion leading to water retention and dilutional hyponatremia.
B: Hypotonicity - Due to water retention, serum osmolality decreases leading to hypotonicity.
C: Anorexia - SIADH can cause nausea, vomiting, and anorexia due to hyponatremia and cerebral edema.
Incorrect choices:
D: Frequent urination - SIADH causes water retention, leading to decreased urine output, not frequent urination.
A 3-year-old patient is taking therapeutic doses of Digoxin and Lasix for heart failure and has an order for daily labs to be drawn. What side effect of this drug combination would the nurse find most concerning?
- A. Hypernatremia
- B. Hypokalemia
- C. Hyponatremia
- D. Hyperkalemia
Correct Answer: B
Rationale: The correct answer is B: Hypokalemia. Digoxin and Lasix can both cause potassium loss, leading to hypokalemia. In this case, hypokalemia is concerning as it can increase the risk of Digoxin toxicity, resulting in life-threatening arrhythmias. Hypernatremia (A), hyponatremia (C), and hyperkalemia (D) are not common side effects of this drug combination and would not pose the same level of risk as hypokalemia.
A six-year-old is scheduled for a cardiac catheterization. Preoperative teaching should be:
- A. Directed to the parents because the patient is too young to understand
- B. Detailed regarding the actual procedure so the patient will know what to expect
- C. Completed several days prior to the procedure so the patient will be prepared
- D. Adapted to the patient's development level
Correct Answer: D
Rationale: The correct answer is D because preoperative teaching for a six-year-old undergoing cardiac catheterization should be adapted to the patient's development level. This is crucial as it ensures the information is communicated in a way that the child can comprehend and reduces anxiety. Providing information at the appropriate developmental stage helps the child feel more prepared and less fearful. Choice A is incorrect as children as young as six can understand basic concepts with appropriate communication techniques. Choice B may overwhelm the child with unnecessary details. Choice C is incorrect because waiting too long to provide information may increase anxiety.
Nurses’ Notes
0640:
Weight 4200 gm (9lb 4 oz), head circumference 35.5cm (14 in)
Respiratory rate 68/min, with mild grunting.
0650:
Respiratory rate 72/min, with mild grunting
0700:
Respiratory rate 76/min, with moderate grunting and mild intercostal retractions
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.
A 16-year-old with a chronic illness has recently become rebellious and is taking risks such as missing doses of his medication. What is the best explanation for this behavior?
- A. The child needs more discipline
- B. The child needs more socialization with peers
- C. The child is exhibiting normal adolescent behavior
- D. The child is demonstrating a need for more parental control
Correct Answer: C
Rationale: The correct answer is C. The child is exhibiting normal adolescent behavior. Adolescence is a period of identity formation, autonomy-seeking, and risk-taking. It is common for teenagers to rebel against authority figures, including parents and healthcare providers, as they strive for independence and self-discovery. This rebellious behavior, such as missing medication doses, can be a way for the teenager to assert control over their own life and make their own decisions. It is crucial for healthcare providers to recognize this normal developmental stage and approach the situation with understanding and support rather than punitive measures.
Other choices are incorrect because:
A: The child needing more discipline implies that the behavior is solely due to a lack of control or structure, which overlooks the developmental aspect of adolescence.
B: While socialization with peers is important, it may not address the underlying reasons for the rebellious behavior.
D: Imposing more parental control may exacerbate the rebellion and hinder the adolescent's autonomy development.