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A school-age child, admitted for intravenous antibiotic therapy for osteomyelitis, reports difficulty in going to sleep at night. Which intervention should the nurse implement to assist the child in going to sleep at bedtime?
- A. Request a prescription for a sleeping pill.
- B. Allow the child to stay up late and sleep late in the morning.
- C. Create a schedule similar to the one the child follows at home.
- D. Plan passive activities in the morning and interactive activities right before bedtime.
Correct Answer: C
Rationale: Creating a schedule similar to the one the child follows at home will provide familiarity and routine, which can help in establishing a bedtime routine and promoting better sleep. Consistency in sleep schedules is important for children, as it helps regulate their circadian rhythm and promotes quality sleep. By mirroring the child's home schedule, the nurse can create a sense of normalcy and comfort for the child, making it easier for them to fall asleep at bedtime. This approach is non-pharmacological and focuses on promoting healthy sleep habits, which is beneficial for the child's overall well-being and recovery process.
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A 6 months old boy presents with respiratory distress and feeding difficulty. On examination heart rate is 130/min and there is a pansystolic murmur at left lower sternal border. What is the most likely diagnosis?
- A. Mitral regurgitation
- B. Mitral valve prolapse
- C. Ventricular septal defect
- D. Coarctation of aorta
Correct Answer: C
Rationale: Ventricular septal defect (VSD) commonly presents with a pansystolic murmur and symptoms of congestive heart failure in infancy.
The nurse is caring for an adolescent brought to the hospital with acute drug toxicity. Cocaine is believed to be the drug involved. Data collection should include what information?
- A. Mode of administration
- B. Drug's actual content
- C. Function the drug plays in the adolescent's life
- D. Adolescent's level of interest in rehabilitation
Correct Answer: A
Rationale: When caring for an adolescent with acute drug toxicity, it is important to gather information on the mode of administration of the drug to understand how it was taken into the body. This information can help the healthcare team determine the extent of drug exposure, potential complications, and appropriate treatment strategies. The mode of administration can include ingestion, inhalation, injection, or other routes, and each method may have different implications for the patient's condition. Understanding how the drug was administered is crucial in managing the adolescent's care effectively.
A nurse is palpating a newborn's fontanels. The nurse documents the anterior fontanel is which shape?
- A. Circle
- B. Triangle
- C. Square
- D. Diamond
Correct Answer: A
Rationale: The anterior fontanel, also known as the bregma, is the larger of the two fontanels located on the baby's skull. It is diamond-shaped, with the sutures meeting in the center to create a space that is soft and slightly depressed. While it is diamond-shaped when looking at the intersection of the sutures, when palpated or touched by a nurse, it often feels more circular due to the softness of the fontanel. It is important for nurses to monitor the fontanels for normal closure and development in newborns.
When assessing a client with autoimmune disorder, what signs should the nurse look for in the client?
- A. Hypotension
- B. Hives or rashes
- C. Localized inflammation
- D. Cramping and vomiting
Correct Answer: B
Rationale: When assessing a client with an autoimmune disorder, the nurse should look for signs such as hives or rashes. Autoimmune disorders can manifest with various skin manifestations, including hives or rashes, which may be indicative of an autoimmune response. These skin manifestations may occur due to the immune system mistakenly attacking the body's own tissues. Observing and monitoring these skin changes can help in assessing and managing the autoimmune disorder in the client. Additionally, localized inflammation may also be present in autoimmune disorders, but hives or rashes are more commonly associated with these conditions.
Which of the ff is a nursing intervention when assessing clients with hypertension?
- A. The nurse takes the temperature when the client is in a standing, sitting, and then supine position
- B. The nurses teaches the client about non pharmacologic and pharmacologic methods for restoring BP
- C. The nurse takes BP in both arms when the client is in a standing, sitting, and then supine position
- D. The nurse weighs the client each morning
Correct Answer: B
Rationale: The nursing intervention of teaching the client about non-pharmacologic and pharmacologic methods for restoring blood pressure is crucial in managing hypertension. Education empowers the client to actively participate in their care and make informed decisions regarding lifestyle changes, medication adherence, and other interventions to control their blood pressure levels. By providing education on interventions such as dietary modifications, exercise, stress management, and medication use, the nurse helps the client develop a comprehensive plan to manage hypertension effectively and improve their overall health outcomes.