Nokea
After providing home care instructions to the mother of a child being discharged following cardiac surgery, which statement made by the mother indicates a need for further instructions?
- A. A balance of rest and exercise is important.
- B. I can apply lotion or powder to the incision if it is itchy.
- C. Activities in which falling could occur need to be avoided for two to four weeks.
- D. Large crowds of people need to be avoided for at least two weeks after the surgery.
Correct Answer: B
Rationale: The correct answer is B. The mother stating that she can apply lotion or powder to the incision if it is itchy indicates a need for further instructions. Applying lotion or powder to the incision is not recommended as it can increase the risk of infection. The other choices are correct: A) Balancing rest and exercise is important for recovery, C) avoiding activities where falling could occur is necessary to prevent injury, and D) avoiding large crowds helps reduce the risk of infections during the initial recovery period.
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During the 'Provide practical treatment' phase, what is the nurse expected to do?
- A. Greet the mother and inquire about the history
- B. Assess for danger signs
- C. Give appropriate treatment
- D. Check vital signs
Correct Answer: C
Rationale: During the 'Provide practical treatment' phase, the nurse is expected to give appropriate treatment to address the patient's needs. This involves implementing the necessary medical interventions or care based on the assessment findings and treatment plan. While greeting the mother, assessing for danger signs, and checking vital signs are important aspects of patient care, the focal point during this phase is to administer the specific treatment required to manage the patient's condition effectively.
A mother visited your facility with the complaint of her child passing watery stools for two days. This is the first time the child is having such an experience. How will you describe such a visit?
- A. Initial
- B. Follow-up
- C. Routine visit
- D. None of the above
Correct Answer: A
Rationale: The correct answer is 'Initial.' This visit is described as initial because it is the first time the child is experiencing these symptoms. It signifies the first encounter with healthcare professionals for this specific issue, distinguishing it from subsequent visits which would be follow-up appointments to monitor progress or routine visits for preventive care. Choice B, 'Follow-up,' is incorrect as it implies subsequent visits after the initial encounter. Choice C, 'Routine visit,' is also incorrect as it implies a scheduled visit for preventive care rather than a visit prompted by a new or acute issue. Choice D, 'None of the above,' is incorrect as one of the options accurately describes the situation, which is 'Initial.'
What comment made by a parent of a 1-month-old would alert the nurse about the presence of a congenital heart defect?
- A. He is always hungry.
- B. He tires out during feedings.
- C. He is fussy for several hours every day.
- D. He sleeps all the time.
Correct Answer: B
Rationale: Observing a 1-month-old tiring out during feedings should alert the nurse to the possibility of a congenital heart defect. This symptom may indicate that the infant is expending excess energy to compensate for a heart issue, leading to fatigue during feeding. Choices A, C, and D do not directly relate to a congenital heart defect. Being always hungry, fussy, or sleeping a lot are not specific signs of a congenital heart defect in a 1-month-old.
Which type of diabetes mellitus (DM) is most likely the result of heterogeneous risk factors, making it preventable?
- A. Type 1
- B. Type 2
- C. Type 1 and 2
- D. Gestational diabetes
Correct Answer: B
Rationale: Type 2 diabetes mellitus is most likely the result of heterogeneous risk factors, such as lifestyle choices and genetics, making it preventable. Type 1 diabetes, on the other hand, is an autoimmune condition that is not preventable. Gestational diabetes occurs during pregnancy and is not entirely preventable. Type 1 and 2 diabetes are distinct conditions, with Type 2 being the type associated with preventable risk factors.
A female child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. Her father is blaming the mother for neglecting the child while she was cooking. On entering the examination room, the child is crying and clinging to the mother. Which data should the nurse obtain first?
- A. Heart rate, respiratory rate, and blood pressure
- B. Recent exposure to communicable diseases
- C. Number of immunizations received
- D. Height and weight
Correct Answer: A
Rationale: In this scenario, the priority is to assess the child's vital signs first, including heart rate, respiratory rate, and blood pressure. These data will provide critical information on the child's current physiological status and guide further interventions. Option B, recent exposure to communicable diseases, is not the priority in an acute ingestion situation. Option C, number of immunizations received, and option D, height and weight, are important but not as critical as assessing vital signs in this immediate situation.