Nokea
A nurse is caring for an infant who has necrotizing enterocolitis. Which of the following findings should the nurse expect?
- A. Hypertension
- B. Rounded abdomen
- C. Vomiting
- D. Tachypnea
Correct Answer: B,C,D
Rationale: The correct answer is B, C, and D. Necrotizing enterocolitis (NEC) in infants commonly presents with a rounded abdomen due to abdominal distension (B). Vomiting (C) is also a common symptom associated with NEC. Tachypnea (D) may occur due to abdominal distension and sepsis. Hypertension (A) is not typically associated with NEC in infants. The other choices are not provided, but based on typical NEC symptoms, they would not be expected in a patient with this condition.
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The nurse is continuing to care for the child. Complete the following sentence by using the list of options. The child is at highest risk of developing------ as evidenced bt the child's------
- A. Deep vein thrombosis
- B. Osteomyelitis
- C. Compartment syndrome
- D. Swelling
- E. Warmth and redness
- F. Paresthesia
- G. Weak pulses
Correct Answer: C,F
Rationale: The correct answer is C, Compartment syndrome, and F, Paresthesia. Compartment syndrome results from increased pressure within a closed anatomical space, leading to compromised blood flow and nerve function. Paresthesia, abnormal sensations like tingling or numbness, is an early sign of nerve compression in compartment syndrome. The combination of these symptoms indicates a critical condition requiring immediate intervention to prevent tissue damage. Choices A, B, D, and E do not align with the clinical presentation of compartment syndrome, whereas choice G, weak pulses, may be seen in severe cases but are not specific enough to be the highest risk factor in this scenario.
A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first?
- A. Notify the client's support person.
- B. Teach the client relaxation techniques.
- C. Help the client identify personal strengths.
- D. Confirm the client's perception of the event.
Correct Answer: D
Rationale: The correct answer is D: Confirm the client's perception of the event. This is the first step because it helps the nurse understand the client's perspective, emotions, and triggers, which are crucial in crisis intervention. By confirming the client's perception, the nurse can establish rapport, validate the client's feelings, and assess the severity of the crisis. This information guides the nurse in developing an appropriate care plan and intervention strategies.
Choice A (Notify the client's support person) may be important but not the first step in crisis intervention. Choice B (Teach the client relaxation techniques) and C (Help the client identify personal strengths) are valuable interventions but should come after assessing the client's perception.
A nurse is caring for a school-age child who has sickle cell anemia and is in vaso-occlusive crisis. Which of the following actions should the nurse take?
- A. Apply cold compresses to the affected areas.
- B. Prepare for a transfusion of platelets.
- C. Promote active range of motion exercises.
- D. Increase oral fluid intake.
Correct Answer: D
Rationale: The correct answer is D: Increase oral fluid intake. During a vaso-occlusive crisis in sickle cell anemia, there is a blockage of blood flow leading to tissue ischemia and pain. Increasing oral fluid intake helps to hydrate the child and improve blood flow, potentially reducing the severity of the crisis. Cold compresses (A) can worsen vasoconstriction, platelet transfusion (B) is not indicated for vaso-occlusive crisis, and active range of motion exercises (C) can exacerbate pain and further compromise blood flow. Increasing fluid intake is the most appropriate intervention to help manage the crisis.
A nurse is teaching a parent of a school-age child who is to begin a daily dose of methylphenidate. Which of the following should the nurse include in the teaching?
- A. Your child should avoid excess sodium intake.
- B. You should administer the medication at bedtime.
- C. Your child should avoid foods containing tyramine.
- D. You should administer the medication after breakfast.
Correct Answer: D
Rationale: The correct answer is D: You should administer the medication after breakfast. Methylphenidate is a stimulant medication commonly used to treat attention deficit hyperactivity disorder (ADHD). Administering it after breakfast helps to minimize potential side effects like decreased appetite and insomnia. It also ensures the medication's effectiveness during the child's school hours. Choice A is incorrect as sodium intake is not specifically contraindicated with methylphenidate. Choice B is incorrect as administering the medication at bedtime can interfere with the child's sleep. Choice C is incorrect as tyramine is not a concern with methylphenidate.
A nurse is planning care for a child during admission to the facility. Which of the following actions should the nurse take first?
- A. Obtain a prescription for pain medication.
- B. Collect blood cultures.
- C. Transport the child to obtain a CT scan.
- D. Initiate seizure precautions.
Correct Answer: D
Rationale: The correct answer is D: Initiate seizure precautions. This should be the first action as it prioritizes the safety of the child. Seizure precautions involve ensuring a safe environment, such as removing any potential hazards and providing padding to prevent injury during a seizure. Collecting blood cultures (B) and obtaining a prescription for pain medication (A) can be important but are not as urgent as ensuring the child's safety in case of a seizure. Transporting the child for a CT scan (C) is not an immediate priority unless there is a critical need.