Nokea
A preschooler with a history of cleft palate repair comes to the clinic for a routine well-child checkup. To determine whether this child is experiencing a long-term effect of cleft palate, which question should the nurse ask the parent?
- A. Does the child play with an imaginary friend?
- B. Was the child recently treated for pneumonia?
- C. Does the child respond when called by name?
- D. Has the child had any difficulty swallowing food?
Correct Answer: C
Rationale: A child with cleft palate is at risk for developing frequent otitis media, which can result in hearing loss. Unresponsiveness may be an indication that the child is experiencing hearing loss. Option 1 is normal behavior for a preschool child. Many preschoolers with vivid imaginations have imaginary friends. Options 2 and 4 are unrelated to cleft palate after repair.
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To assure the desired results, how should the nurse instruct the client prescribed oral bisacodyl to take the medication?
- A. At bedtime
- B. With a large meal
- C. With a glass of milk
- D. On an empty stomach
Correct Answer: A
Rationale: Bisacodyl is a stimulant laxative that works by stimulating peristalsis in the colon. To ensure its effectiveness, it should be taken at bedtime to produce a bowel movement in the morning, typically 6 to 12 hours after administration. Taking it with a large meal or milk may reduce its effectiveness due to delayed gastric emptying or interaction with food. Taking it on an empty stomach may cause stomach irritation and is not necessary for its action.
During a health assessment, the client tells the nurse that she was diagnosed with endometriosis. Which explanation presented by the client demonstrates an understanding of the description of the condition?
- A. Endometriosis is known as primary dysmenorrhea.
- B. Endometriosis is what causes me the pain that occurs when I ovulate.
- C. Endometriosis is the condition that has caused me to stop menstruating.
- D. Endometriosis means that I have uterine tissue growing outside my uterus.
Correct Answer: D
Rationale: Endometriosis is defined as the presence of tissue outside the uterus that resembles the endometrium in structure, function, and response to estrogen and progesterone during the menstrual cycle. Mittelschmerz refers to pelvic pain that occurs midway between menstrual periods coinciding with ovulation. Primary dysmenorrhea refers to menstrual pain without identified pathology. Amenorrhea, the cessation of menstruation for a period of at least 3 cycles or 6 months in a woman who has established a pattern of menstruation, can result from a variety of causes.
The nurse is preparing a client diagnosed with Graves' disease to receive radioactive iodine therapy. What information should the nurse share with the client about the therapy?
- A. After the initial dose, subsequent treatments must continue lifelong.
- B. The radioactive iodine is designed to destroy the entire thyroid gland with just one dose.
- C. It takes 6 to 8 weeks after treatment to experience relief from the symptoms of the disease.
- D. High radioactivity levels prohibit contact with family for 4 weeks after the initial treatment.
Correct Answer: C
Rationale: Graves' disease is also known as toxic diffuse goiter and is characterized by a hyperthyroid state resulting from hypersecretion of thyroid hormones. After treatment with radioactive iodine therapy, a decrease in the thyroid hormone level should be noted, which helps alleviate symptoms. Relief of symptoms does not occur until 6 to 8 weeks after initial treatment. Occasionally, a client may require a second or third dose, but treatments are not lifelong. This form of therapy is not designed to destroy the entire gland; rather, some of the cells that synthesize thyroid hormone will be destroyed by the local radiation. The nurse must reassure the client and family that unless the dosage is extremely high, clients are not required to observe radiation precautions. The rationale for this is that the radioactivity quickly dissipates.
The nurse provides discharge instructions to a client who is recovering from testicular cancer surgery. Which instruction should the nurse include?
- A. To avoid driving a car for at least 2 weeks
- B. Not to be fitted for a prosthesis for at least 3 months
- C. To avoid sitting for long periods for at least 2 weeks
- D. To report any elevation in temperature to the primary health care provider
Correct Answer: D
Rationale: For the client who has had testicular surgery, the nurse should emphasize the importance of notifying the primary health care provider if chills, fever, drainage, redness, or discharge occurs. These symptoms may indicate the presence of an infection. One week after testicular surgery, the client may drive. Often, a prosthesis is inserted during surgery. Sitting needs to be avoided with prostate surgery because of the risk of hemorrhage, but this risk is not as high with testicular surgery.
The nurse is planning to give a tepid tub bath to a child experiencing hyperthermia. Which action should the nurse plan to perform?
- A. Obtain isopropyl alcohol to add to the bath water.
- B. Allow 5 minutes for the child to soak in the bath water.
- C. Have cool water available to add to the warm bath water.
- D. Warm the water to the same body temperature as the child's.
Correct Answer: C
Rationale: Adding cool water to an already warm bath allows the water temperature to slowly drop. The child is able to gradually adjust to the changing water temperature and will not experience chilling. Alcohol is toxic, can cause peripheral vasoconstriction, and is contraindicated for tepid sponge or tub baths. The child should be in a tepid tub bath for 20 to 30 minutes to achieve maximum results. To achieve the best cooling results, the water temperature should be at least 2 degrees lower than the child's body temperature.