Nokea
After performing an assessment of an infant with bladder exstrophy, the nurse prepares a plan of care. The nurse identifies which problem as the priority for the infant?
- A. Urinary incontinence
- B. Impaired tissue integrity
- C. Inability to suck and swallow
- D. Lack of knowledge about the disease (parents)
Correct Answer: B
Rationale: In bladder exstrophy, the bladder is exposed and external to the body, leading to impaired tissue integrity related to the exposed bladder mucosa as the priority problem. Urinary incontinence is not a concern as the infant is not yet toilet trained. Inability to suck and swallow is unrelated to the disorder. While educating the parents about the condition is important, it is not the priority over addressing the immediate risk of impaired tissue integrity in the infant.
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The parent of an infant diagnosed with gastroesophageal reflux disease is receiving feeding instructions from the nurse. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis?
- A. Provide smaller, more frequent feedings.
- B. Burp the infant frequently during feedings.
- C. Thin the feedings by adding water to the formula.
- D. Thicken the feedings by adding rice cereal to the formula.
Correct Answer: D
Rationale: Gastroesophageal reflux disease involves the backward flow of gastric contents into the esophagus due to sphincter issues. To reduce episodes of emesis, it is recommended to thicken feedings by adding rice cereal to the formula. This helps to weigh down the contents in the stomach, making regurgitation less likely. Providing smaller, more frequent feedings and burping the infant frequently are beneficial strategies for gastroesophageal reflux. However, in this case, thickening the feedings is the most appropriate intervention. Thinning the feedings by adding water to the formula is not recommended as it can decrease the caloric density of the formula and may not help in reducing reflux.
A client with Multiple Sclerosis reports a constant, burning, tingling pain in the shoulders. The nurse anticipates that the physician will order which medication for this type of pain?
- A. alprazolam (Xanax)
- B. Corticosteroid injection
- C. gabapentin (Neurontin)
- D. hydrocodone/acetaminophen (Norco)
Correct Answer: C
Rationale: For neuropathic pain associated with conditions like Multiple Sclerosis, medications like gabapentin, an anticonvulsant, are commonly used. Gabapentin helps in managing nerve pain by stabilizing electrical activity in the brain and nervous system. Alprazolam is a benzodiazepine used for anxiety and not primarily indicated for neuropathic pain. Corticosteroid injections are more suitable for inflammatory conditions like arthritis, not for neuropathic pain. Hydrocodone/acetaminophen is an opioid combination used for moderate to severe pain, but it is not the first-line choice for neuropathic pain.
A patient is undergoing a stress test on a treadmill and turns to talk to the nurse. Which of these statements would require the most immediate intervention?
- A. I'm feeling extremely thirsty and will get some water after this.
- B. I can feel my heart racing.
- C. My shoulder and arm are hurting.
- D. My blood pressure reading is 158/80
Correct Answer: C
Rationale: The correct answer is 'C: My shoulder and arm are hurting.' Unilateral arm and shoulder pain are classic symptoms of myocardial ischemia, indicating possible heart issues. In this scenario, immediate intervention is required, and the stress test should be halted. Choice A about feeling thirsty does not indicate an acute medical issue. Choice B mentioning heart racing is expected during a stress test. Choice D, a blood pressure reading of 158/80, while slightly elevated, does not present an immediate concern compared to the symptoms of arm and shoulder pain suggesting cardiac distress.
During an assessment of a child admitted to the hospital with a probable diagnosis of nephrotic syndrome, what assessment findings should the nurse expect to observe? Select one that applies.
- A. Proteinuria
- B. Weight gain
- C. Decreased serum lipids
- D. Hematuria
Correct Answer: A
Rationale: In nephrotic syndrome, the hallmark finding is massive proteinuria due to increased glomerular permeability. This leads to hypoalbuminemia, resulting in generalized edema. Weight gain, not weight loss, is typically seen due to fluid retention. Serum lipids are elevated, not decreased, in nephrotic syndrome. Hematuria, the presence of blood in the urine, is not a typical finding in nephrotic syndrome.
The child with hemolytic-uremic syndrome is anuric and will undergo peritoneal dialysis. Which measure should the nurse implement?
- A. Restrict fluids as prescribed.
- B. Care for the arteriovenous fistula.
- C. Encourage foods high in potassium.
- D. Administer analgesics as prescribed.
Correct Answer: A
Rationale: In hemolytic-uremic syndrome, often associated with bacterial toxins and viruses, acute kidney injury occurs in children, leading to symptoms like anemia, thrombocytopenia, renal injury, and CNS symptoms. For an anuric child with hemolytic-uremic syndrome undergoing peritoneal dialysis, fluid restriction is vital to prevent fluid overload. Pain management is not directly related to hemolytic-uremic syndrome. Foods high in potassium should be limited, not encouraged, due to impaired kidney function. Peritoneal dialysis does not involve an arteriovenous fistula, which is specific to hemodialysis.