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A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse?
- A. "A man should wear a latex condom during intimate sexual contact."
- B. "I've heard about people who got AIDS from blood transfusions."
- C. "I won't donate blood because I don't want to get AIDS."
- D. "IV drug users can get HIV from sharing needles."
Correct Answer: C
Rationale: It is important for the nurse to clarify to the student that donating blood does not put them at risk for getting AIDS. Blood donation centers follow strict protocols to ensure that donated blood is safe for transfusion, including screening for infectious diseases like HIV. It is admirable to donate blood as it can save lives without putting the donor at risk for acquiring HIV. It is crucial to dispel any misconceptions or fears surrounding blood donation to encourage people to participate in this important act of altruism.
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Aling Loida, who was admitted for acute pancreatitis, starts complaining of acute abdominal pain, which of the following would be an appropriate nursing interventions by Nurse Norma?
- A. administer morphine sulfate as ordered
- B. obtain daily weights
- C. maintain Aling Loida on high calorie, high protein diet
- D. place her on supine position
Correct Answer: A
Rationale: Administering morphine sulfate as ordered would be an appropriate nursing intervention for Aling Loida who is complaining of acute abdominal pain. Morphine is a potent analgesic that can help alleviate severe pain. Pain management is crucial in acute pancreatitis to help the patient feel more comfortable and to improve their overall well-being. It is important to follow the healthcare provider's orders regarding the administration of pain medication to ensure effective pain relief for the patient.
While examining a 2-year-old child, Nurse Galina sees that the anterior fontanel is open. She should:
- A. Notify the doctor
- B. Look for other signs of abuse
- C. Recognize this as a normal finding
- D. Ask about a family history of Tay-Sachs disease
Correct Answer: C
Rationale: Nurse Galina should recognize an open anterior fontanel as a normal finding in a 2-year-old child. The anterior fontanel is a soft spot on a baby's skull where the skull bones have not yet fused together. It usually closes by the time a child is 18 to 24 months old. The open fontanel at 2 years of age is within the normal range of closure, and it is not a cause for concern in this case. No need to notify the doctor, look for other signs of abuse, or ask about a family history of Tay-Sachs disease based on this finding.
A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. While an airway is being established, the nurse should prepare which medication for immediate administration?
- A. Diphenhydramine (Benadryl)
- B. Dobutamine (Dobutarex)
- C. Epinephrine (Adrenalin)
- D. Calcium chloride (calcium chloride)
Correct Answer: C
Rationale: In the management of anaphylaxis, the immediate medication of choice for administration is epinephrine. Epinephrine is a potent vasoconstrictor and bronchodilator which helps restore blood pressure and open up the airways during an anaphylactic reaction. It is the first-line treatment to reverse the potentially life-threatening effects of an allergic reaction. Other medications, like diphenhydramine or dobutamine, may be used as adjuncts later in the treatment, but epinephrine is crucial for immediate administration to stabilize the child's condition.
A nurse explains to a child's parents that the role of methotrexate (Rheumatrex®) in treating children with juvenile arthritis is to:
- A. decrease the inflammatory response.
- B. improve functional ability.
- C. control the febrile response.
- D. minimize the effects of uveitis.
Correct Answer: A
Rationale: Methotrexate, which is a disease-modifying antirheumatic drug (DMARD), is commonly used to treat juvenile arthritis by decreasing the inflammatory response in the joints. By suppressing the overactive immune response that causes inflammation in the joints, methotrexate helps reduce pain, swelling, and stiffness in children with juvenile arthritis. This ultimately helps to improve joint function and prevent joint damage. While methotrexate may indirectly contribute to improving functional ability and controlling febrile responses in some cases, its primary mechanism of action is to target and reduce inflammation in juvenile arthritis. The medication may also help in managing associated conditions like uveitis, but its main role lies in decreasing the inflammatory response in arthritis.
Hindbrain herniation or the Chiari type II malformation is seen in which percent of individuals with myelomeningocele
- A. 10-20%
- B. 20-30%
- C. 40-50%
- D. 80-90%
Correct Answer: D
Rationale: Chiari type II malformation is strongly associated with myelomeningocele, occurring in approximately 80-90% of cases due to abnormal cerebellar development and cranial settling.