Nokea
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema?
- A. I wake up to go to the bathroom at night.
- B. My shoes fit tighter by the end of the day.
- C. I seem to be feeling more anxious lately.
- D. I drink at least eight glasses of water a day.
Correct Answer: B
Rationale: Tight-fitting shoes by the end of the day suggest fluid retention (edema), a common sign of cardiovascular or renal issues.
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A 3-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. Which sign or symptom suggests excessive I.V. fluid intake?
- A. Worsening dyspnea
- B. Gastric distension
- C. Nausea and vomiting
- D. Temperature of 102°F (38.9° C)
Correct Answer: A
Rationale: Worsening dyspnea may indicate fluid overload, leading to pulmonary edema and respiratory distress.
The following statements are true of bronchiolitis:
- A. Up to 50% of patients continue to wheeze after recovery
- B. The typical pathogen is para-influenza virus
- C. Corticosteroid therapy is beneficial
- D. Tachypnoea is invariable
Correct Answer: A
Rationale: Wheezing after bronchiolitis is common. The typical pathogen is respiratory syncytial virus, not para-influenza. Corticosteroids are not routinely beneficial, and tachypnoea is common but not invariable.
A patient with no structural heart disease: a wide QRS tachycardia of RBBB morphology at a rate of 160 bpm, QRS axis of (-) 40 degrees and AV dissociation was recorded during palpitation. What is the likely diagnosis?
- A. RV outflow ventricular tachycardia
- B. Posterior fascicular VT
- C. Anterior fascicular VT
- D. Antidromic AVRT
Correct Answer: A
Rationale: RV outflow ventricular tachycardia is the likely diagnosis given the RBBB morphology and QRS axis.
The wife of a client with Parkinson's disease expresses concern because her husband has lost so much weight. Which teaching is best for the nurse to provide?
- A. Invite friends over regularly to share in meal times
- B. Encourage the client to drink clear liquids between meals
- C. Coach the client to make an intentional effort to swallow
- D. Talk to the healthcare provider about prescribing an appetite stimulant
Correct Answer: A
Rationale: Social interaction during meals can improve appetite and intake in clients with Parkinson's disease.
A 7-year-old child who has a history of a repaired congenital heart defect (CHD)has many dental caries along with gingival erythema and irritation and a temperature of 102.5°F. What will the primary care pediatric nurse practitioner do next?
- A. Admit to the hospital with a pediatric cardiology consult.
- B. Obtain blood cultures and a CBC and consult a pediatric cardiologist.
- C. Refer the child to a pediatric dental surgeon immediately.
- D. Start prophylactic antibiotics such as penicillin twice daily for 2 weeks.
Correct Answer: A
Rationale: Children who are suspected of having SBE should be admitted to the hospital and referred to pediatric cardiology.