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A school nurse observes a child, with a peanut allergy, in obvious distress, wheezing and cyanotic, after ingestion of some trail mix containing peanuts. Place the interventions the nurse should implement in order of the highest priority to the lowest priority. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d).
- A. Call Jason's parents and notify them of the situation.
- B. Call Jason's family practitioner to obtain further orders for medication.
- C. Promptly administer an intramuscular dose of epinephrine. TestBankWorld.org
- D. Call 911 and wait for the emergency response personnel to arrive.
Correct Answer: c
Rationale: The highest priority intervention in this situation is 'C': Promptly administer an intramuscular dose of epinephrine. Epinephrine is The first-line treatment for anaphylaxis, which is a severe allergic reaction that can be life-threatening. Administering Epinephrine as soon as possible can help reverse The symptoms and stabilize The child.
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The nurse is teaching the parents of a child with developmental dysplasia of the hip (DDH) regarding the application of the Pavlik harness. Which of the following information should the nurse include in the teaching?
- A. Three diapers should be worn at all times under the harness.
- B. Harness should be removed for ten minutes every hour.
- C. Harness should always keep the legs fully adducted.
- D. Clothing should always fit loosely over the harness.
Correct Answer: D
Rationale: The correct information that the nurse should include in the teaching is that clothing should always fit loosely over the harness. This is important to prevent restriction of movement and ensure comfort for the child wearing the Pavlik harness. Tight clothing can cause discomfort, skin irritation, and interfere with the effectiveness of the harness in positioning the hip properly. Parents should be advised to choose clothing that is loose-fitting and does not put pressure on the harness or the child's skin.
The nurse is assessing a child with croup and a sore throat in the ED. The child is drooling and agitated. The nurse should know that examining the child's throat using a tongue depressor might precipitate which of the following?
- A. Profuse coughing
- B. Inspiratory stridor
- C. Complete obstruction
- D. Increased agitation
Correct Answer: C
Rationale: When assessing a child with croup who is drooling and agitated, the nurse should be aware that examining the throat using a tongue depressor can potentially precipitate a complete airway obstruction. Croup is characterized by upper airway inflammation, particularly around the larynx and trachea, leading to a barking cough, hoarseness, and respiratory distress. In a child with croup who is already showing signs of airway compromise such as drooling and agitation, any manipulation in the throat area can cause further swelling and lead to a complete obstruction of the airway. This can be a life-threatening emergency requiring immediate intervention to secure the airway and ensure adequate oxygenation. Therefore, utmost caution should be taken when performing any procedures that may exacerbate the child's respiratory distress in this situation.
In assessing a post mastectomy client, the nurse determines that the client is in denial. The nurse can best respond by:
- A. Accepting the denial.
- B. Supporting the denial.
- C. Confronting the denial.
- D. Interpreting the denial.
Correct Answer: C
Rationale: Confronting the denial is the best response in this situation. Denial is a common defense mechanism that individuals may use when faced with overwhelming emotions or situations, such as in the case of a post-mastectomy client. By confronting the denial in a supportive and empathetic manner, the nurse can help the client acknowledge and accept their feelings, which is an important step in the healing and coping process. Ignoring or supporting the denial may hinder the client's ability to address their emotions and work through them effectively. Confronting the denial allows for open communication and helps the client move towards acceptance and adjustment.
Which is descriptive of central nervous system stimulants?
- A. They produce strong physical dependence.
- B. They can result in strong psychological dependence.
- C. Withdrawal symptoms are life threatening.
- D. Acute intoxication can lead to coma.
Correct Answer: B
Rationale: Central nervous system (CNS) stimulants, such as amphetamines and cocaine, are known to produce strong psychological dependence in individuals who use them. These substances can create a powerful craving for their effects due to their ability to increase alertness, attention, and euphoria. Psychological dependence can lead to compulsive drug-seeking behavior, even in the absence of physical withdrawal symptoms. It is important to note that while CNS stimulants can lead to physical dependence, it is typically not as pronounced as the psychological dependence that can develop.
Poor prognostic factors in Hodgkin lymphoma include all the following EXCEPT
- A. age of more than 15 year at the time of diagnosis
- B. stage IV disease
- C. manifested by positron emission tomography (PET) scan positivity
- D. presence of bulky mediastinal mass
Correct Answer: A
Rationale: Older age is generally considered a poor prognostic factor, but not necessarily worse than other listed options.