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An adolescent patient with chronic asthma, who has been hospitalized several times during the winter with severe asthmatic exacerbations, confides, 'I wish I could stay here in the hospital because every time I go home, I get sick again!' What is the pediatric nurse's best response?
- A. Let's talk about preventing and managing your asthma on a daily basis at home.
- B. Why don't I speak with your parents about what they are doing at home to help control your asthma?
- C. We can arrange for you to stay in the hospital longer.
- D. none of the above.
Correct Answer: A
Rationale: Discussing strategies to manage asthma at home empowers the patient and addresses the root cause of recurrent exacerbations.
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How are young people with anorexia nervosa often described?
- A. Independent
- B. Disruptive
- C. Conforming
- D. Low achieving
Correct Answer: A
Rationale: Young people with anorexia nervosa are often described as independent. This is because individuals with anorexia nervosa tend to exhibit strong willpower and control over their behavior, often making independent decisions related to their eating habits and body image. They may resist help or intervention, preferring to maintain control over their food intake and weight loss. This independence can make it challenging to address and treat anorexia nervosa effectively, as individuals may be resistant to seeking or accepting help.
A Jewish client has been diagnosed with ulcerative colitis. A nursing diagnosis appropriate for a client who has ulcerative colitis is:
- A. abdominal pain related to decreased peristalsis
- B. diarrhea related to hyperosmolar intestinal contents
- C. fluid volume excess related to increase water absorption by intestinal mucosa
- D. activity intolerance related to fatigue
Correct Answer: A
Rationale: Among the given choices, the nursing diagnosis appropriate for a client with ulcerative colitis is "abdominal pain related to decreased peristalsis." Ulcerative colitis is a chronic inflammatory bowel disease that directly affects the lining of the colon and rectum, leading to symptoms such as abdominal pain, diarrhea, and bloody stool. Decreased peristalsis occurs in patients with ulcerative colitis, resulting in abdominal pain due to inflammation and irritation of the intestines. This pain is a common symptom experienced by individuals with ulcerative colitis and can significantly impact their quality of life. Therefore, addressing the client's abdominal pain is crucial in providing effective nursing care for someone diagnosed with ulcerative colitis.
The nurse is caring for an infant with a suspected urinary tract infection. Which clinical manifestations should be expected? (Select all that apply.)
- A. Vomiting
- B. Jaundice
- C. Failure to gain weight
- D. Swelling of the face
Correct Answer: A
Rationale: A urinary tract infection (UTI) in an infant may present with symptoms such as vomiting and failure to gain weight. Vomiting can be a common sign of UTI in infants due to irritation and inflammation in the urinary tract. Additionally, infants with UTIs may experience poor feeding and failure to gain weight due to the discomfort and systemic effects of the infection. While symptoms like jaundice, swelling of the face, back pain, and persistent diaper rash can be seen in other conditions, they are not typically associated with a urinary tract infection in infants.
A client has malignant lymphoma. As part of her chemotherapy, the physician prescribes chlorambucil (Leukeran), 10mg by mouth daily. When caring for the client, the nurse teaches her about adverse reactions to chlorambucil, such as alopecia. How soon after the first administration of chorambucil might this reaction occur?
- A. Immediately
- B. 2 to 3 weeks
- C. 1 week
- D. 1 month
Correct Answer: B
Rationale: Alopecia (hair loss) is a common adverse reaction to chlorambucil, which typically occurs within 2 to 3 weeks of starting treatment. This is because chemotherapy drugs like chlorambucil target rapidly dividing cells, which also includes hair follicles leading to hair loss. Patients should be informed about this potential side effect so that they can be prepared for it and explore options like wearing wigs or scarves if they wish.
What should nursing interventions to maintain a patent airway in a newborn include?
- A. Sleeping in the prone (on abdomen) position
- B. Wrapping neonate as snugly as possible
- C. Positioning neonate supine while sleeping
- D. Using bulb syringe to suction as needed, suctioning nose first, and then pharynx
Correct Answer: D
Rationale: Nursing interventions to maintain a patent airway in a newborn should prioritize safety and best practices. Positioning the neonate supine while sleeping is crucial to reduce the risk of sudden infant death syndrome (SIDS) and ensure proper airway alignment. Using a bulb syringe to suction as needed, with the correct technique of suctioning the nose first and then the pharynx, helps effectively remove secretions and keep the airway clear. This intervention promotes optimal respiratory function and reduces the risk of airway obstruction in newborns. Sleeping in the prone position is not recommended due to the increased risk of SIDS. Wrapping the neonate as snugly as possible can also pose risks of overheating and compromising the airway, making it an unsafe practice.