Nokea
An 8-year-old girl asks the nurse how the blood pressure apparatus works. What is the most appropriate nursing action?
- A. Ask her why she wants to know.
- B. Determine why she is so anxious.
- C. Explain in simple terms how it works.
- D. Tell her she will see how it works as it is used.
Correct Answer: C
Rationale: The most appropriate nursing action when an 8-year-old girl asks how the blood pressure apparatus works is to explain in simple terms how it works. Children are curious by nature and providing a simple explanation in a language they can understand helps satisfy their curiosity and also promotes their understanding. By explaining how the blood pressure apparatus works, the nurse can educate the child about a common medical device and reduce any anxiety or fear the child may have about it. This approach encourages the child to feel more comfortable and engaged in their healthcare experience.
You may also like to solve these questions
A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
- A. Weight gain
- B. Respiratory acidosis
- C. Fine motor tremors
- D. Bilateral hearing loss
Correct Answer: D
Rationale: Prolonged aspirin therapy can lead to a rare side effect known as aspirin-induced hearing loss, which manifests as bilateral hearing loss. This adverse reaction is typically associated with higher doses of aspirin and longer durations of use. It is important for healthcare providers to monitor for signs of hearing loss in patients receiving long-term aspirin therapy, especially those with rheumatoid arthritis or other inflammatory conditions, to prevent irreversible damage to the hearing. Weight gain, respiratory acidosis, and fine motor tremors are not commonly associated with prolonged aspirin therapy.
Which of the ff instructions should be given to the clients family if a client with impaired swallowing has to take solid medication?
- A. Mix the medication with food
- B. Use the liquid form of the medication
- C. Check with the physician or pharmacist before crushing or breaking tablets, or opening capsules
- D. Perform ROM exercises after the medication is administered
Correct Answer: C
Rationale: It is important to instruct the client's family to check with the physician or pharmacist before crushing or breaking tablets, or opening capsules for a client with impaired swallowing who needs to take solid medication. Many medications have special formulations or coating that may alter their effectiveness if not taken whole. Consulting with a healthcare professional ensures that the medication remains safe and effective when modifying its form for a client with difficulty swallowing. Mixing the medication with food (option A) may also alter its effectiveness, so it is crucial to seek guidance before making any changes to the medication form. Using the liquid form of the medication (option B) may be a suitable alternative if available; however, this decision should also be discussed and approved by the healthcare provider. Performing ROM exercises after medication administration (option D) is unrelated to addressing the issue of impaired swallowing and medication administration.
A client has a serum calcium level of 7.2mg/dl. During the physical examination, the nurse expects to assess:
- A. Trousseau's sign
- B. Hegar's sign
- C. Homan's sign
- D. Goodell's sign
Correct Answer: A
Rationale: A client with a low serum calcium level (hypocalcemia) is at risk for exhibiting Trousseau's sign. Trousseau's sign is a clinical manifestation of hypocalcemia characterized by carpal spasm induced by inflating a blood pressure cuff on the arm above the systolic pressure for a few minutes. This spasm occurs due to the increased neuromuscular irritability caused by low calcium levels. Therefore, a nurse assessing a client with a serum calcium level of 7.2mg/dl should expect to assess Trousseau's sign.
Children with ALL who carry poor outcome include all the following EXCEPT
- A. age younger than 1 year and older than 10 year
- B. T-cell immunophenotype
- C. hyperdiploidy chromosomal abnormality
- D. initial leukocyte count of > 50,000
Correct Answer: C
Rationale: Hyperdiploidy is generally associated with a favorable prognosis in ALL, unlike other listed factors.
Justine is admitted to the pediatric unit due to the occurrence of diabetic ketoacidosis signaling a new diagnosis of diabetes. The diabetes team explores the cause of the episode and take steps to prevent a recurrence. Diabetic ketoacidosis (DKA) results from an excessive accumulation of which of the following?
- A. Sodium bicarbonate from renal compensation
- B. Potassium from cell death
- C. Glucose from carbohydrate metabolism
- D. Ketone bodies from fat metabolism
Correct Answer: D
Rationale: Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when there is not enough insulin in the body. In the absence of sufficient insulin, the body is unable to use glucose for energy, leading to the breakdown of fats for fuel. This results in the excessive production of ketone bodies, specifically acetoacetate and beta-hydroxybutyrate. As the ketone bodies accumulate in the blood, they lower the blood pH, leading to acidosis. This is what causes the characteristic symptoms of DKA, such as fruity breath, deep rapid breathing, and abdominal pain. Therefore, the excessive accumulation of ketone bodies from fat metabolism is the primary cause of diabetic ketoacidosis.