Nokea
An infant with a large patent ductus arteriosus
A nurse is collecting data from an infant a large patent ductus arteriosus. Which of the following is clinical manifestations should the nurse expect?
- A. Machine like murmur
- B. Chronic hypoxemia
- C. Cyanosis with crying
- D. Weak pulse
Correct Answer: A
Rationale: The correct answer is A: Machine-like murmur. A patent ductus arteriosus (PDA) is a congenital heart defect where a blood vessel called the ductus arteriosus fails to close after birth, causing abnormal blood flow. The characteristic murmur associated with PDA is described as machine-like due to its continuous and loud nature. This murmur is heard best at the upper left sternal border. Other choices are incorrect because chronic hypoxemia (B) and cyanosis with crying (C) are more commonly seen in conditions like Tetralogy of Fallot or transposition of great vessels. Weak pulse (D) may be present in conditions like coarctation of the aorta.
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A child who has Kawasaki disease
A nurse is caring for a child who has Kawasaki disease. Which of the following systems is primarily affected by this disease?
- A. Respiratory
- B. Gastrointestinal
- C. Cardiovascular
- D. Integumentary
Correct Answer: C
Rationale: The correct answer is C: Cardiovascular. Kawasaki disease primarily affects the cardiovascular system, causing inflammation of blood vessels, particularly the coronary arteries. This can lead to complications such as coronary artery aneurysms and myocarditis. The other choices are incorrect because Kawasaki disease does not primarily affect the respiratory, gastrointestinal, or integumentary systems. The key feature of Kawasaki disease is the inflammation of blood vessels, which is why the cardiovascular system is the primary system affected.
A 2-month-old infant who has just undergone cleft palate repair
A nurse is contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the client's plan of care?
- A. Keep the infant in a side-lying position.
- B. Remove elbow restraints while the infant is sleeping
- C. Administer pain medication around the clock for the first 72 hr.
- D. Feed the infant half-strength formula for the first 48 hr
Correct Answer: C,D
Rationale: Correct Answer: C, D
Rationale:
C: Administer pain medication around the clock for the first 72 hr to ensure adequate pain management post-cleft palate repair.
D: Feed the infant half-strength formula for the first 48 hr to prevent potential aspiration and promote healing.
Summary:
A: Keeping the infant in a side-lying position is not directly related to cleft palate repair care.
B: Removing elbow restraints while the infant is sleeping may increase the risk of self-injury.
E, F, G: No additional information provided, so cannot determine their relevance.
A 9-year-old child who has acute rheumatic fever
A nurse is assisting with the admission of a 9-year-old child who has acute rheumatic fever. When obtaining the client's history, it is appropriate for the nurse to ask the parent which of the following questions?
- A. Has your son had a sore throat recently?
- B. Was your son born with this cardiac defect?
- C. Are you aware that your son will have to be in isolation?
- D. Has your child had any injuries recently?
Correct Answer: A
Rationale: Rationale: A sore throat can be a symptom of acute rheumatic fever, which is important for the nurse to assess. This can help in diagnosing the condition and planning appropriate care. Asking about a recent sore throat is relevant to the child's current health status and can guide further assessment and treatment.
Summary:
B: This question is not relevant to acute rheumatic fever.
C: Isolation is not necessary for acute rheumatic fever, so this question is not appropriate.
D: Recent injuries are not directly related to acute rheumatic fever and are not relevant to the child's current condition.
A school-age child who has cystic fibrosis
A nurse is reinforcing teaching with the parents of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make?
- A. Your child's diet should be high in carbohydrates & proteins with no restriction of fats.
- B. Limit your child's intake of sodium to avoid complications.
- C. A pigeon-shaped chest might become evident as the disease progresses.
- D. Administer a bronchodilator to the child after chest percussion therapy.
Correct Answer: C
Rationale: The correct answer is C: A pigeon-shaped chest might become evident as the disease progresses. In cystic fibrosis, the chest may appear pigeon-shaped due to the abnormal growth of the ribs and sternum. This is caused by chronic respiratory issues and increased work of breathing. It is important for the nurse to educate the parents about this potential physical manifestation of the disease so they can monitor their child's condition closely.
Incorrect choices:
A: Your child's diet should be high in carbohydrates & proteins with no restriction of fats - This is incorrect as children with cystic fibrosis often require a high-calorie, high-fat diet to meet their increased energy needs.
B: Limit your child's intake of sodium to avoid complications - While monitoring sodium intake can be important for some conditions, it is not a primary concern in cystic fibrosis.
D: Administer a bronchodilator to the child after chest percussion therapy - While bronchodilators may be used in cystic fib
A child who has cystic fibrosis
A nurse is reinforcing discharge instructions with a parent of a child who has cystic fibrosis. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will restrict the amount of salt in my child's meals.
- B. I will put my child in daycare to ensure that she socializes with other children.
- C. I will make sure my child washes her hands before eating.
- D. I will provide low-fat meals for my child.
Correct Answer: C
Rationale: The correct answer is C: "I will make sure my child washes her hands before eating." This statement indicates an understanding of the teaching because proper handwashing is crucial in preventing infections in individuals with cystic fibrosis who are more susceptible to respiratory infections. By washing hands before eating, the child can reduce the risk of exposure to harmful pathogens.
Choice A is incorrect because restricting salt intake is not a priority in managing cystic fibrosis. Choice B is incorrect as the focus should be on hygiene and health rather than socialization. Choice D is incorrect as children with cystic fibrosis actually require a higher calorie and fat intake.