Nokea
An 8-month-old infant has a hypercyanotic spell while blood is being drawn. What is the priority nursing action?
- A. Assess for neurologic defects
- B. Place the child in the knee-chest position
- C. Begin cardiopulmonary resuscitation
- D. Prepare family for imminent death
Correct Answer: B
Rationale: When an 8-month-old infant has a hypercyanotic spell, the priority nursing action is to place the child in the knee-chest position. This position helps to increase venous return to the heart and improve systemic circulation, which can relieve the cyanosis by decreasing right-to-left shunting of blood. Placing the child in the knee-chest position helps optimize oxygenation and circulation, which is crucial during a hypercyanotic spell. Assessing for neurologic defects, beginning cardiopulmonary resuscitation, or preparing the family for imminent death are not the priority actions during a hypercyanotic spell in this scenario.
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A client with Hashimoto's thyroiditis and a history of two myocardial infarctions and coronary artery disease is to receive levothyroxine (Synthroid). Because of the client's cardiac history, the nurse would expect that the client's initial dose for the thyroid replacement would be which of the following?
- A. 25 g/day, initially
- B. Delayed until after thyroid surgery
- C. 100 g/day, initially
- D. Initiated before thyroid surgery
Correct Answer: A
Rationale: In a client with a history of two myocardial infarctions and coronary artery disease, initiating levothyroxine therapy with a low starting dose of 25 mcg/day is recommended. Thyroid hormone replacement therapy can potentially worsen underlying cardiac conditions, so a cautious approach is necessary. The dose may be gradually titrated upwards based on thyroid function tests and the client's response. Delaying treatment until after thyroid surgery (option B) is not necessary in this scenario if the client requires thyroid hormone replacement. Initiating levothyroxine before thyroid surgery (option D) is not relevant to the given clinical situation. Starting with a higher dose of 100 mcg/day (option C) may pose a higher risk of cardiac complications in this client with a cardiac history.
Which side effects should the nurse monitor when a child is taking an antipsychotic medication? (Select all that apply.)
- A. Extrapyramidal effects
- B. Hypertension
- C. Bradycardia
- D. Dizziness
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a high-risk newborn with an umbilical catheter in a radiant warmer. The nurse notes blanching of the feet. Which is the most appropriate nursing action?
- A. Elevate feet 15 degrees.
- B. Place socks on newborn.
- C. Wrap feet loosely in prewarmed blanket.
- D. Report findings immediately to the practitioner.
Correct Answer: C
Rationale: When the nurse notes blanching of the feet in a high-risk newborn with an umbilical catheter in a radiant warmer, the most appropriate nursing action is to wrap the feet loosely in a prewarmed blanket. Blanching indicates poor circulation to the area, which can be a result of cold stress or constriction of blood vessels. By wrapping the feet in a prewarmed blanket, the nurse can help to restore adequate blood flow to the feet and improve circulation. This action addresses the potential cause of the blanching and promotes the newborn's comfort and well-being.
Bell's palsy is a ___ cranial nerve disorder characterized by weakness or paralysis of the facial muscles.
- A. 3rd
- B. 7th
- C. 5th
- D. 8th
Correct Answer: B
Rationale: Bell's palsy is a cranial nerve disorder characterized by weakness or paralysis of the facial muscles due to inflammation, compression, or damage to the seventh cranial nerve - the facial nerve. The facial nerve controls the muscles responsible for facial expressions and functions like smiling, closing the eyes, and raising the eyebrows. Symptoms of Bell's palsy can include drooping of one side of the face, difficulty in closing one eye, drooling, impaired taste, and difficulty in smiling.
Why should the nurse wake up a client who is to undergo an EEG at midnight?
- A. Because excess sleep may make the client lazy and nervous for the EEG
- B. Because optimum sleep helps regulate the breathing patterns during the EEG
- C. Because it helps the client to fall asleep naturally during the EEG
- D. Because it reduces the chances of getting a headache when electrodes are fixed to the scalp of the client
Correct Answer: B
Rationale: The nurse should wake up a client who is to undergo an EEG at midnight to ensure that the client receives optimum sleep before the procedure. Optimum sleep helps regulate the client's breathing patterns during the EEG, resulting in more accurate readings. Adequate rest is essential for brain activity monitoring to be as normal as possible. Waking the client at midnight allows for enough time for the client to fall back asleep before the EEG is conducted, ensuring the best possible conditions for the procedure.