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A parent asks the nurse "when will my infant start to teethe?" The nurse responds that the earliest age at which an infant begins teething with eruption of lower central incisors is _____ months.
- A. 4
- B. 6
- C. 8
- D. 12
Correct Answer: B
Rationale: The earliest age at which an infant typically begins teething with the eruption of their lower central incisors is around 6 months old. Teething typically starts around this age, but it can vary from one infant to another. It is important to note that while 6 months is a common age for teething to begin, some infants may start teething a little earlier or later. It's essential for parents to monitor their baby's development and seek guidance from healthcare professionals if needed.
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Fentanyl is used as analgesia during operative and postoperative procedures. Which of the following conditions is NOT associated with fentanyl use?
- A. Tachycardia
- B. Hypotension
- C. Nausea and vomiting
- D. Acidosis
Correct Answer: D
Rationale: Fentanyl typically causes hypotension, nausea, and vomiting, but it does not cause acidosis.
The nurse observes the temperature record of a client and relates the fever to the brain infection the client currently has. The nurse knows that a high temperature may lead to an increased cerebral irritation. Which of the ff measures can help the nurse control the clients body temperature? Choose all that apply
- A. Providing tepid sponge bath
- B. Applying ice packs
- C. Administering prescribed antipyretics
- D. Keeping the room temperature warm
Correct Answer: A
Rationale: A. Providing tepid sponge bath: This measure helps to gradually lower the body temperature by promoting heat loss through evaporation. It is a safe and effective way to cool down someone with a fever.
While caring for a patient who is hospitalized for acute gastroenteritis and dehydration, the pediatric nurse notes that the patient's parent keeps packets of herbs by the patient's bedside. Suspecting that the parent may be administering the herbs to the patient, the nurse's first action is to:
- A. ask the parent in a nonjudgmental manner about the herbs.
- B. coordinate a nursing care conference to discuss the patient's plan of care.
- C. discuss the risks of using alternative therapies with the parent.
- D. refer the family to a social worker for possible nonadherence with the healthcare regimen.
Correct Answer: A
Rationale: A nonjudgmental approach encourages open communication and allows the nurse to assess the situation appropriately.
The nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketonic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?
- A. Elevated serum acetone level
- B. Serum alkalosis
- C. Serum ketone bodies
- D. Below-normal serum potassium level
Correct Answer: D
Rationale: Hyperosmolar hyperglycemic nonketonic syndrome (HHNS) is characterized by extremely elevated blood glucose levels without significant ketosis. Unlike diabetic ketoacidosis (DKA), patients with HHNS usually do not have high levels of ketone bodies in their blood or urine. Therefore, the nurse should anticipate below-normal serum potassium levels in a client with HHNS, as hyperglycemia can lead to profound potassium losses through osmotic diuresis. Monitoring and treating electrolyte imbalances, including hypokalemia, are crucial in managing HHNS. It is important to correct these imbalances promptly to prevent further complications.
Which assessment finding would prompt the Rn to suspect compartment syndrome in a patient with a long leg cast?
- A. weak movement of the patient's toes
- B. decreased pedal pulses
- C. severe, unrelieved pain
- D. presence of foot pallor
Correct Answer: C
Rationale: Compartment syndrome is a serious condition that can occur when increased pressure within a muscle compartment impairs blood supply, leading to tissue ischemia and potential necrosis. Symptoms of compartment syndrome include severe, unrelieved pain that is disproportionate to the injury, as well as pain with passive stretch of the affected muscles. This pain is often described as deep, constant, and out of proportion to physical findings. Other signs that may indicate compartment syndrome include pallor, pulselessness, paresthesia, and paralysis, but the most specific and early sign is severe, unrelieved pain. While weak movement of the patient's toes and decreased pedal pulses can also be seen in compartment syndrome, they are not as specific or early indicators as severe, unrelieved pain.