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A preschool child is scheduled for an echocardiogram. Parents ask the nurse whether they can hold the child during the procedure. The nurse should answer with which response?
- A. "You will be able to hold your child during the procedure."
- B. "Your child can be active during the procedure, but can't sit in your lap."
- C. "Your child must lie quietly; sometimes a mild sedative is administered before the procedure."
- D. "The procedure is invasive so your child will be restrained during the echocardiogram."
Correct Answer: A
Rationale: The correct response is that "You will be able to hold your child during the procedure." It is common for parents to be allowed to hold their child during an echocardiogram to provide comfort and reassurance. This can help the child stay calm and cooperative during the procedure. Holding the child can also create a familiar and secure environment, making it easier for the healthcare provider to perform the echocardiogram successfully.
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The single parent of a 3-year-old child who has just been diagnosed with chickenpox tells the nurse that she cannot afford to stay home with the child and miss work. The parent asks the nurse if some medication will shorten the course of the illness. Which is the most appropriate nursing intervention?
- A. Reassure the parent that it is not necessary to stay home with the child.
- B. Explain that no medication will shorten the course of the illness.
- C. Explain the advantages of the medication acyclovir (Zovirax) to treat chickenpox.
- D. Explain the advantages of the medication VCZ immune globulin (VariZIG) to treat chickenpox.
Correct Answer: B
Rationale: The most appropriate nursing intervention in this scenario is to explain to the parent that no medication will shorten the course of chickenpox. Chickenpox is a viral illness caused by the varicella-zoster virus, and there is no specific treatment to shorten its duration. Antiviral medications like acyclovir are typically reserved for severe cases or for individuals with compromised immune systems. VCZ immune globulin (VariZIG) is used for post-exposure prophylaxis in susceptible individuals who have been exposed to chickenpox and are at high risk for severe disease.
The nurse should expect a client with hypothyroidism to report which health concerns?
- A. Increased appetite and weight loss
- B. Nervousness and tremors
- C. Puffiness of the face and hands
- D. Thyroid gland swelling
Correct Answer: C
Rationale: Hypothyroidism is characterized by an underactive thyroid gland that does not produce enough thyroid hormone. This hormonal imbalance can lead to symptoms such as slow metabolism, weight gain, fatigue, cold intolerance, constipation, and puffiness of the face and hands. The slowed metabolic rate can also cause fluid retention, resulting in the characteristic puffiness associated with hypothyroidism. Increased appetite and weight loss are not typical symptoms of hypothyroidism, as the condition is more commonly associated with weight gain. Nervousness and tremors are more indicative of hyperthyroidism, where the thyroid gland is overactive. Thyroid gland swelling, known as goiter, can occur in various thyroid disorders but is not specific to hypothyroidism.
Blood and fluid loss from frequent diarrhea may cause hypovolemia and you can quickly assess volume depletion in Miss CC by:
- A. Measuring the quantity and specific gravity of her urine output
- B. Taking her blood pressure
- C. Comparing the patient's present weight with her last weight
- D. Administering the oral water test
Correct Answer: C
Rationale: Comparing the patient's present weight with her last weight is the best way to quickly assess volume depletion in Miss CC. As she has been experiencing frequent diarrhea leading to blood and fluid loss, changes in weight are a reliable indicator of changes in the body's fluid status. A significant decrease in weight would suggest a loss of fluid and potential hypovolemia due to the diarrhea. This method is simple, immediate, and directly reflects the impact of the fluid loss on the body's volume status. Measuring the quantity and specific gravity of her urine output could provide information on her kidney function but may not be as quick and direct in evaluating volume depletion as comparing her current weight with her last recorded weight. Taking her blood pressure is important in assessing overall cardiovascular status but may not be as immediate in reflecting the impact of fluid loss on volume status. Administering the oral water test is not a standard method for quickly assessing volume depletion in this scenario.
A nurse is collecting subjective and objective information about target populations to diagnose problems based on community needs. This describes which step in the community nursing process?
- A. Planning
- B. Diagnosis
- C. Assessment
- D. Establishing objectives
Correct Answer: C
Rationale: In the community nursing process, the step of collecting subjective and objective information about target populations to diagnose problems based on community needs is known as "Assessment." This step involves gathering data through observation, interviews, surveys, and other methods to understand the health status, priorities, assets, and resources of the community. This information is essential for identifying the health needs and issues within the community, which then informs the planning and implementation of appropriate interventions. Assessment helps nurses develop a comprehensive understanding of the community's strengths, challenges, and opportunities, enabling them to make informed decisions and tailor interventions to meet the specific needs of the target population.
The nurse is taking care of a 2-year-old child with a macule skin lesion. Which clinical finding should the nurse expect to assess with this type of lesion?
- A. Flat, nonpalpable, and irregularly shaped lesion that is greater than 1 cm in diameter
- B. Heaped-up keratinized cells, flaky exfoliation, irregular, thick or thin, dry or oily, varied in size
- C. Flat, brown mole less than 1 cm in diameter
- D. Elevated, flat-topped, firm, rough, superficial papule greater than 1 cm in diameter
Correct Answer: A
Rationale: A macule is a flat, nonpalpable, and discolored area on the skin that is less than 1 cm in diameter. This type of skin lesion is typically characterized by a change in color without any change in texture or thickness of the skin. The clinical finding associated with a macule is a flat, nonpalpable lesion that is smaller in size (less than 1 cm) and regularly shaped. Therefore, the nurse should expect to assess a flat, nonpalpable, and irregularly shaped lesion that is greater than 1 cm in diameter with a different type of skin lesion, not a macule.