Nokea
A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank for 20 minutes. Which of the following is the most important instruction the nurse can give the parent?
- A. This too shall pass.
- B. Take the child immediately to the ER
- C. Contact the Poison Control Center quickly
- D. Give the child syrup of ipecac
Correct Answer: C
Rationale: In situations where a child has ingested a potentially harmful substance, contacting the Poison Control Center quickly is crucial. The Poison Control Center can provide specific guidance tailored to the child's situation, which can include whether immediate medical attention is necessary or if any actions need to be taken at home. Option A, 'This too shall pass,' is not appropriate as it dismisses the seriousness of the situation. Option B, 'Take the child immediately to the ER,' may not always be the best course of action without guidance from experts. Option D, 'Give the child syrup of ipecac,' is outdated advice and not recommended as a first response to poisoning incidents.
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Which playroom activities should the nurse organize for a small group of 7-year-old hospitalized children?
- A. Sports and games with rules.
- B. Finger paints and water play.
- C. "Dress-up"? clothes and props.
- D. Chess and television programs
Correct Answer: A
Rationale: For 7-year-old children, play serves an important role in developing cooperation, logical reasoning, and social skills. Organizing sports and games with rules is beneficial as it helps children understand the importance of rules, promotes teamwork, and fosters social interactions. Finger paints and water play, while fun, may not target the specific developmental needs of this age group. Similarly, 'Dress-up' clothes and props can encourage imaginative play but may not necessarily promote cooperation and logical reasoning. Chess and television programs are more suited for older children and may not engage 7-year-olds as effectively in developing the desired skills.
When measuring the vital signs of a 6-month-old infant, which action by the nurse is correct?
- A. Respirations are measured first, followed by pulse and temperature.
- B. Vital signs should be measured as frequently as in an adult.
- C. Procedures are explained to the parent, and the infant is encouraged to handle the equipment.
- D. The nurse should first measure the infant's vital signs before performing a physical examination.
Correct Answer: A
Rationale: When assessing vital signs in a 6-month-old infant, the correct order is to measure respirations first, followed by pulse and temperature. This sequence is important to avoid potential alterations in respiratory and pulse rates caused by factors like crying or discomfort. Measuring the temperature first, especially rectally, may lead to an increase in respiratory and pulse rates, which can skew the results. It is crucial to follow this specific order to obtain accurate baseline values. Therefore, option A is the correct choice. Option B is incorrect as the frequency of measuring vital signs in infants differs based on individual needs rather than being consistently more frequent than in adults. Option C is not directly related to the correct sequence for measuring vital signs in infants. Option D is incorrect because the physical examination typically follows the assessment of vital signs in clinical practice.
During an examination, the nurse notices that a female patient has a round "moon"? face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse determines that the patient likely has which condition?
- A. Gigantism
- B. Acromegaly
- C. Cushing syndrome
- D. Marfan syndrome
Correct Answer: C
Rationale: Cushing syndrome is characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and a round, plethoric face (moon face). Excessive catabolism in Cushing syndrome causes muscle wasting, weakness, thin arms and legs, reduced height, and thin, fragile skin with purple abdominal striae, bruising, and acne. Gigantism is characterized by increased height and weight and delayed sexual development, which are not present in the patient. Acromegaly results from excessive growth hormone secretion in adulthood, leading to bone overgrowth in specific areas like the face, head, hands, and feet. Marfan syndrome is an inherited connective tissue disorder characterized by a tall, thin stature and distinct features not seen in this patient. The combination of signs described in the question aligns with the clinical presentation of Cushing syndrome.
A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive
drug. He reports feeling dizzy at times. How would the nurse evaluate his blood pressure?
- A. Blood pressure and pulse should be recorded in the supine, sitting, and standing
positions. - B. The patient should be directed to walk around the room and his blood pressure
assessed after this activity. - C. Blood pressure and pulse are assessed at the beginning and at the end of the
examination. - D. Blood pressure is taken on the right arm and then 5 minutes later on the left arm.
Correct Answer: A
Rationale: Orthostatic vital signs should be taken when the person is hypertensive or is taking antihypertensive
medications, when the person reports fainting or syncope, or when volume depletion is suspected.
The blood pressure and pulse readings are recorded in the supine, sitting, and standing positions.
Patients who cannot move in their bed on their own should be turned at least ________________.
- A. once a day
- B. twice a day
- C. every 2 hours
- D. every 4 hours
Correct Answer: C
Rationale: Patients who are unable to move in bed are at high risk of developing pressure ulcers and skin breakdown due to prolonged pressure on specific body areas. Turning these patients at least every 2 hours is crucial to relieve pressure, improve circulation, and prevent skin damage. More frequent turning may be necessary for patients with specific needs, such as those who are incontinent of urine and require additional care. Turning patients less frequently, such as once a day, twice a day, or every 4 hours, increases the risk of developing pressure ulcers and other complications. Therefore, the correct answer is to turn patients who cannot move in their bed on their own every 2 hours.