Nokea
An 8-day-old is admitted with vomiting and dehydration. His HR is 170, RR is 44, BP is 85/52, and T is 99°F. The parents ask if these vital signs are normal. Which is the best response?
- A. The BP is elevated.
- B. The temperature is elevated.
- C. The heart rate is elevated; normal for a neonate is 90-160 bpm.
- D. The respiratory rate is elevated.
Correct Answer: C
Rationale: A neonatal heart rate of 170 is above the normal range (90-160 bpm), which is concerning for dehydration.
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Which blood gas analyses are most indicative of respiratory acidosis?
- A. pH = 7.22, PCO2 = 55 mmHg, HCO3 = 30 mEq/L.
- B. pH = 7.28, PCO2 = 45 mmHg, HCO3 = 15 mEq/L.
- C. pH = 7.34, PCO2 = 35 mmHg, HCO3 = 25 mEq/L.
- D. pH = 7.40, PCO2 = 25 mmHg, HCO3 = 30 mEq/L.
Correct Answer: A
Rationale: Respiratory acidosis is indicated by a low pH and elevated PCO2, as seen in option A.
The nurse is caring for a 5-year-old child with impetigo contagiosa. The parents ask the nurse what will happen to their child's skin after the infection has subsided and healed. Which answer should the nurse give?
- A. There will be no scarring.
- B. There may be some pigmented spots.
- C. It is likely there will be some slightly depressed scars.
- D. There will be some atrophic white scars.
Correct Answer: A
Rationale: Impetigo contagiosa typically does not leave scarring once it has subsided and healed. This skin infection primarily affects the superficial layers of the skin and does not cause damage deep enough to result in scarring. While there may be some temporary pigmented spots or mild changes in skin color after the infection resolves, scarring is not a common outcome of impetigo contagiosa in most cases. Thus, the nurse should reassure the parents that their child's skin is not likely to have any scarring after the infection has healed.
A male client who is HIV positive is admitted to the hospital with a diagnosis of Pneumocystis carinii pneumonia. His live-in partner has accompanied him. During the history interview, the nurse is aware of feeling a negative attitude about the client's lifestyle, what action is most appropriate?
- A. Share these feelings with the client
- B. Discuss the negative feelings with the
- C. Develop a written interview form charge nurse
- D. Avoid eye contact with the client
Correct Answer: B
Rationale: It is important for the nurse to acknowledge and address any negative feelings or biases that may arise during patient care, especially when caring for a patient with a stigmatized condition like HIV/AIDS. Discussing these negative feelings with a trusted colleague, such as the charge nurse, can help the nurse process and overcome their biases in a safe and non-judgmental environment. By addressing these feelings, the nurse can ensure that they provide compassionate and professional care to the patient and their partner without any personal biases interfering with the care delivery. Sharing these feelings with the client or avoiding eye contact would be inappropriate and counterproductive to establishing trust and providing care. Developing a written interview form would not address the underlying issue of negative attitudes or biases and may not be effective in promoting unbiased care.
The nurse is caring for a child after heart surgery. What should the nurse do if evidence of cardiac tamponade is found?
- A. Increase analgesia
- B. Apply warming blankets
- C. Immediately report this to physician
- D. Encourage child to cough, turn, and breathe deeply
Correct Answer: C
Rationale: If evidence of cardiac tamponade is found in a child after heart surgery, it is crucial for the nurse to immediately report this to the physician. Cardiac tamponade is a serious condition where excess fluid or blood accumulates in the pericardial sac, compressing the heart and affecting its ability to pump effectively. Prompt recognition and intervention are essential to prevent potential life-threatening outcomes. The physician would need to assess the child's condition, consider performing procedures to relieve the tamponade such as pericardiocentesis, and provide appropriate treatment to stabilize the child. Delaying reporting and action in cases of cardiac tamponade can lead to further complications and worsen the child's condition.
Which is true of a Wilms tumor? (Select all that apply.)
- A. It is also referred to as neuroblastoma.
- B. It is most commonly seen between the ages of 2 and 5 years.
- C. It can occur on its own or be associated with congenital anomalies.
- D. It is a slow-growing tumor.
Correct Answer: C
Rationale: Wilms tumor typically occurs in children aged 2-5 years and may be associated with congenital anomalies. It is not the same as neuroblastoma, and its prognosis is generally good with treatment.