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An infant with tetralogy of Fallot becomes cyanotic and dyspneic after a crying episode. To relieve the cyanosis and dyspnea, the nurse should place the infant in the:
- A. Orthopneic position
- B. Knee-chest position
- C. Lateral Sims' position
- D. Semi-Fowler's position
Correct Answer: A
Rationale: The orthopneic position is the best position to relieve cyanosis and dyspnea in an infant with tetralogy of Fallot. This position involves sitting up and leaning forward, which helps improve lung expansion and oxygenation. Placing the infant in the orthopneic position will reduce the workload on the heart, improve oxygenation, and relieve symptoms of cyanosis and dyspnea associated with tetralogy of Fallot. It allows for better expansion of the lungs and improves ventilation-perfusion matching, thereby enhancing oxygen exchange and alleviating the cyanotic spell.
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When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. What is the best explanation for this?
- A. Some form of cancer
- B. Local scalp infection common in children
- C. Infection or inflammation distal to the site
- D. Infection or inflammation close to the site
Correct Answer: D
Rationale: In this case, the tenderness, enlargement, and warmth of the child's cervical lymph nodes are likely due to an infection or inflammation that is close to the site. When lymph nodes are palpated and found to be tender, enlarged, and warm, it often indicates that the lymphatic system is responding to an infection or inflammation in the nearby area. The lymph nodes are part of the body's immune system and can become enlarged and tender as they work to fight off the infection. In this scenario, the most likely explanation is an infection or inflammation located near the cervical lymph nodes.
Which of the following instructions should be included in the discharge teaching plan for a client after thyroidectomy for Grave's disease?
- A. keep an accurate record of intake and output.
- B. use nasal desmopressin acetate (DDAVP).
- C. be sure to get regular follow-up care.
- D. Be sure to exercise to improve cardiovascular fitness.
Correct Answer: C
Rationale: Regular follow-up care is crucial after a thyroidectomy for Grave's disease to monitor the patient's thyroid hormone levels, assess for signs of complications such as hypothyroidism or hypoparathyroidism, and ensure appropriate management of any related conditions. Routine follow-up visits with healthcare providers allow for ongoing assessment and adjustment of medications, as well as addressing any concerns the patient may have post-surgery. By emphasizing the importance of regular follow-up care, the healthcare team can provide necessary support and guidance to the patient throughout their recovery process.
Nurse Jeremy is evaluating a client's fluid intake and output record. Fluid intake and urine output should relate in which way?
- A. Fluid intake should be double the urine output.
- B. Fluid intake should be approximately equal to the urine output.
- C. Fluid intake should be half the urine output.
- D. Fluid intake should be inversely proportional to the urine output.
Correct Answer: B
Rationale: The principle of fluid balance in the body dictates that fluid intake should be approximately equal to the urine output, under normal circumstances. This balance ensures that the body maintains proper hydration levels and that the kidneys are functioning effectively in filtering and excreting waste products. Significant deviations between fluid intake and urine output can indicate potential issues with hydration status or kidney function, making it essential for healthcare professionals like Nurse Jeremy to closely monitor and evaluate these values.
The parents of a newborn ask the nurse what caused the baby's facial nerve paralysis. What knowledge should the nurse's response be based on?
- A. Genetic defect
- B. Birth injury
- C. Spinal cord injury
- D. Inborn error of metabolism
Correct Answer: B
Rationale: Facial nerve paralysis in a newborn is most commonly caused by birth injury. This can occur during the birthing process due to pressure on the baby's face or head, particularly if forceps or vacuum extraction are used during delivery. The trauma can affect the facial nerve resulting in temporary or permanent paralysis. It is important for the nurse to provide reassurance to the parents that birth injury is a common cause of facial nerve paralysis in newborns, and in many cases, the paralysis resolves on its own over time without further complications.
The following are warning signs of cancer. Which one is not?
- A. Change In bladder and bowel habits
- B. Weight gain
- C. Indigestion or difficulty in swallowing
- D. Nagging cough or hoarseness
Correct Answer: B
Rationale: Weight gain is not typically considered a warning sign of cancer. In fact, unexplained weight loss is more commonly associated with certain types of cancer. The other options all relate to symptoms that could potentially be warning signs of cancer and are worth discussing with a healthcare professional for further evaluation.