A nurse is interviewing the parents of a toddler about use of complementary or alternative medical practices. The parents share several practices they use in their household. Which should the nurse document as complementary or alternative medical practices? (Select all that apply.)
- A. Use of acetaminophen (Tylenol) for fever
- B. Administration of chamomile tea at bedtime
- C. Hypnotherapy for relief of pain
- D. Acupressure to relieve headaches
Correct Answer: B
Rationale: Administration of chamomile tea at bedtime is considered a complementary medical practice, as it involves the use of an herb for its potential therapeutic effects.
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A 3-week-old neonate is brought to the emergency department because of a three-day history of intermittent vomiting. His mother reports that he has not urinated for eight hours. On physical examination, his eyes are sunken. Which of the following will MOST likely require correction before surgery is performed?
- A. Hypochloremia
- B. Hyperkalemia
- C. Hypernatremia
- D. N/A
Correct Answer: A
Rationale: Hypochloremia is often associated with dehydration and metabolic alkalosis, which may need correction before surgery.
Which vein should be used first when initiating IV therapy?
- A. Jugular
- B. Basilic
- C. Brachiocephalic
- D. Axillary
Correct Answer: B
Rationale: When initiating IV therapy, the basilic vein is often used first due to its accessibility and size. The basilic vein is a common choice for venipuncture because it is located on the medial aspect of the arm and tends to be easily palpable. Additionally, the basilic vein is also less prone to complications such as nerve damage compared to other deeper veins like the jugular or brachiocephalic veins. Therefore, utilizing the basilic vein as the initial site for IV therapy is a safe and efficient choice.
Hyperparathyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction would experience:
- A. Heat intolerance and systolic
- B. Diastolic hypertension and widened hypertension pulse pressure
- C. Weight gain and heat intolerance
- D. Anorexia and hyper-excitability
Correct Answer: A
Rationale: Hyperparathyroidism is caused by increased levels of parathyroid hormone (PTH), not thyroxine. The effects of hyperparathyroidism include increased calcium levels in the blood, which can lead to symptoms such as heat intolerance and systolic hypertension. Systolic hypertension is when the top number in a blood pressure reading is elevated. This is why option A (heat intolerance and systolic hypertension) is the correct choice for a client with hyperparathyroidism. Options B, C, and D do not accurately reflect the symptoms associated with this endocrine dysfunction.
A first-time mother brings in her 5-day-old baby for a well-child visit. The baby weighs 7 lb 5 oz, down from 7 lb 10 oz at discharge. The nurse's best response is:
- A. I will notify the doctor about this weight loss.
- B. Newborns can lose up to 10% of their birth weight and regain it by 2 weeks of age.
- C. I can tell you are a first-time mother; don't worry.
- D. Maybe the baby isn't getting enough milk. How often are you feeding?
Correct Answer: B
Rationale: A small weight loss is normal in the first week of life; infants typically regain their birth weight by 2 weeks.
The child who walks backward, scribbles, and uses spoon and fork has achieved the developmental age of
- A. 9 mo
- B. 12 mo
- C. 15 mo
- D. 18 mo
Correct Answer: D
Rationale: These milestones are typically achieved around 18 months of age.