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Which action by a nurse indicates that the nurse requires further education? Select all that apply.
- A. The nurse monitors the child's vital signs every 2 to 4 hours
- B. The nurse carefully washes his/her hands before and after providing care
- C. The child has been placed in a semi-private room
- D. The nurse assesses the child for clinical signs of an infection
Correct Answer: C
Rationale: Rationale: The correct answer is C because placing a child in a semi-private room violates privacy and confidentiality. Nurses should prioritize patient privacy. A: Monitoring vital signs is a standard nursing practice. B: Handwashing is essential for infection control. D: Assessing for signs of infection is part of nursing assessment. Summary: A, B, and D are appropriate nursing actions, while C violates patient privacy.
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Which of the following statements should the nurse include in the discussion about sickled red blood cells? Select all that apply.
- A. Sickled red blood cells are flexible, making it easier for these cells to travel through small vessels
- B. Sickled red blood cells are c-shaped and tend to stick together more easily
- C. Sickled red blood cells have a long-life span. Therefore, they circulate in the blood longer than healthy cells
- D. Sickled red blood cells are rigid, making it difficult for the cells to travel through smaller vessels
- E. Sickled red blood cells have a short life span which decreases the number of red blood cells circulating in the blood
Correct Answer: B,D,E
Rationale: The correct statements to include in the discussion about sickled red blood cells are B, D, and E.
B: Sickled red blood cells are c-shaped and tend to stick together more easily, leading to vaso-occlusive crises.
D: Sickled red blood cells are rigid, making it difficult for them to travel through smaller vessels, causing blockages and tissue damage.
E: Sickled red blood cells have a short life span, decreasing the number of red blood cells circulating in the blood, leading to anemia and tissue hypoxia.
These statements are crucial for understanding the pathophysiology of sickle cell disease and the complications associated with it.
Statements A, C, F, and G are incorrect as they do not accurately describe the characteristics or implications of sickled red blood cells.
When administering oral iron supplements to a client with anemia, the nurse should take which action to ensure optimal absorption?
- A. Crush the iron supplement and mix it with applesauce
- B. Administer the iron supplement with a glass of milk
- C. Discontinue and contact provider if client's stools become a tarry green color
- D. Administer the iron supplement with a vitamin C-rich drink
Correct Answer: D
Rationale: The correct answer is D: Administer the iron supplement with a vitamin C-rich drink. Vitamin C enhances iron absorption by converting iron into a more absorbable form. This helps the body utilize iron more effectively to combat anemia. Crushing iron supplements with applesauce (A) may decrease absorption as it may bind to the food. Administering with milk (B) is not recommended as calcium can inhibit iron absorption. Discontinuing if stools are tarry green (C) is relevant for monitoring side effects.
Which of the following is a complication of hemophilia?
- A. Hematuria
- B. Hemarthrosis
- C. Hemoptysis
- D. Hematemesis
Correct Answer: B
Rationale: Answer B, Hemarthrosis, is correct. Hemophilia is a bleeding disorder where blood doesn't clot normally. Hemarthrosis, or bleeding into joints, is a common complication due to joint trauma. Hematuria (A) is blood in urine, not specific to hemophilia. Hemoptysis (C) is coughing up blood, more common in lung conditions. Hematemesis (D) is vomiting blood, seen in gastrointestinal issues. In hemophilia, bleeding into joints (hemarthrosis) is a key complication due to lack of clotting factors.
How do preschool-aged children typically understand death? Select all that apply.
- A. They may believe that death is punishment for bad behavior
- B. They may believe that death is temporary or reversible
- C. They may have a fear of death and view it as something to be avoided
- D. They understand death as a natural part of the life cycle
- E. They may believe that death is caused by their thoughts
- F. They have a concrete understanding of death as a permanent cessation of life
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. Preschool-aged children often have limited understanding of death. A) They may believe death is punishment due to their egocentric thinking, linking consequences to behavior. B) They may see death as temporary or reversible, influenced by their cognitive development. E) They may think their thoughts can cause death due to magical thinking. These choices align with typical preschool perspectives on death. Incorrect options include C) Fear of death is common but not the only way children understand it. D) While some children grasp death as natural, it may not be universal. F) Concrete understanding of death as permanent typically develops later.
Which of the following should the nurse monitor in the child? Select all that apply.
- A. Manifestations that could indicate a sepsis infection
- B. Long-term effects that result from a prolonged recovery
- C. Blood pressure that could indicate hypertension
- D. Heart problems that result from cardiac dysfunction
- E. A decrease in body temperature as a sign of bacterial meningitis progression
Correct Answer: A,B,C
Rationale: Step 1: Monitoring manifestations of sepsis infection is crucial in children as they are more vulnerable to infections due to their developing immune systems.
Step 2: Long-term effects from prolonged recovery need to be monitored to ensure the child's overall health and well-being post-illness.
Step 3: Monitoring blood pressure in children is important to identify any potential hypertension early on for prompt intervention.
Summary:
- Choice D is incorrect as it specifically mentions heart problems resulting from cardiac dysfunction, which is not a general monitoring requirement for children.
- Choice E is incorrect as a decrease in body temperature is not a typical sign of bacterial meningitis progression.
- Choices F and G were not provided but would also be considered incorrect as they were not listed as correct monitoring parameters for children.