Nokea
A nurse is working in a neonatal intensive care unit (NICU). The nurse wants to teach a mother of a premature baby how to give her baby a bath. Which statement by the mother reflects a readiness to learn?
- A. "You'll give us written instructions before we go home, correct?"
- B. "When my baby is just a little bigger, I'll feel more comfortable giving him a bath."
- C. "I want to make sure my husband is here, in case I don't hear everything that's said."
- D. "I'm so afraid I'll hurt my baby with all these tubes and wires."
Correct Answer: A
Rationale: The statement "You'll give us written instructions before we go home, correct?" reflects the mother's readiness to learn. This statement shows that the mother is actively seeking out resources and tools to help her understand and remember the instructions for giving her premature baby a bath. It indicates that she is willing to take responsibility for her baby's care and is thinking ahead to ensure she has the necessary information for when she is on her own at home. This statement demonstrates engagement and a proactive approach to learning, which are essential for successfully caring for a premature baby in a NICU setting.
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The nurse is caring for a client with congestive heart failure (CHF) who frequently wakes during the night frightened and short of breath. Based on this data, what is the client experiencing?
- A. Cardiomyopathy
- B. Paroxysmal nocturnal dyspnea
- C. High-output failure
- D. Multisystem heart failure
Correct Answer: B
Rationale: Paroxysmal nocturnal dyspnea is a symptom commonly seen in patients with congestive heart failure (CHF). It is characterized by sudden awakening from sleep due to difficulty breathing and feeling of suffocation. This occurs because when the patient lies down, the redistribution of fluid in the body leads to increased fluid in the lungs, causing difficulty in breathing. Patients with CHF often experience worsening of symptoms at night, including paroxysmal nocturnal dyspnea, due to the shift in fluid dynamics in a supine position. Therefore, the client in this scenario is likely experiencing paroxysmal nocturnal dyspnea, a classic symptom of heart failure exacerbation.
The nurse is caring for an adult client who was diagnosed with a congenital heart defect as a child, which was later repaired with surgery. Which common complication of a heart defect should the nurse monitor that the client may still be at risk for?
- A. Deep vein thrombosis
- B. Endocarditis
- C. Atherosclerosis
- D. Shock
Correct Answer: B
Rationale: Endocarditis is a common complication that individuals with repaired congenital heart defects may still be at risk for. Endocarditis is an infection of the inner lining of the heart chambers and valves. The altered structure of the heart tissue from the previous defect and surgery can create an increased risk for bacterial growth and infection. Patients with a history of congenital heart defects should be monitored for signs and symptoms of endocarditis, such as fever, fatigue, new heart murmurs, and evidence of systemic embolization. Prophylactic antibiotics before certain dental and surgical procedures may be recommended to prevent endocarditis in this population. Therefore, the nurse should be vigilant in monitoring for any symptoms suggestive of endocarditis in this client.
What causes brown pigmentation of the lower extremities in clients with venous stasis?
- A. The necrosis of subcutaneous fat due to tissue hypoxia
- B. Breakdown of red blood cells in the congested tissues
- C. Reduced inflammatory and immune response from congested circulation
- D. Skin atrophy caused by lack of circulation
Correct Answer: B
Rationale: The brown pigmentation of the lower extremities in clients with venous stasis is primarily caused by the breakdown of red blood cells in the congested tissues. When there is venous stasis, the blood circulation is impaired, leading to a backup of blood in the lower extremities. This stagnant blood contains hemosiderin, a byproduct of red blood cell breakdown. Over time, the hemosiderin deposits in the tissues, causing the characteristic brown discoloration seen in conditions such as chronic venous insufficiency. This process is known as hemosiderin deposition and is a common consequence of venous stasis.
An adult client is experiencing paroxysmal supraventricular tachycardia. Which nursing interventions are appropriate based on the data provided? Select all that apply.
- A. Initiate oxygen therapy
- B. Prepare for cardioversion
- C. Begin anticoagulation therapy as prescribed
- D. Administer intravenous adenosine as prescribed
Correct Answer: A
Rationale: A. Initiate oxygen therapy: Providing oxygen therapy is appropriate to ensure adequate oxygenation and tissue perfusion during episodes of paroxysmal supraventricular tachycardia.
The nurse hears a grating sound while assessing the range of motion of a patient’s hip. How should the nurse document this finding?
- A. Crackles
- B. Arthritis
- C. Synovitis
- D. Crepitation
Correct Answer: D
Rationale: Crepitation refers to a grating sound or sensation that occurs when there is rubbing together of the roughened articular surfaces of bones within a joint. It is commonly associated with conditions such as osteoarthritis or joint injury. Therefore, if the nurse hears a grating sound while assessing the range of motion of a patient's hip, the appropriate documentation of this finding would be crepitation.