Nokea
Austin, age 6 months, has six teeth. How should the nurse interpret this finding?
- A. Normal tooth eruption
- B. Delayed tooth eruption
- C. Unusual and dangerous
- D. Earlier-than-normal tooth eruption
Correct Answer: A
Rationale: The eruption of teeth in infants typically begins around 6 months of age, with the lower central incisors being the first to appear. Having six teeth at 6 months old is within the normal range of tooth eruption for infants. The average time frame for infants to have their first teeth is between 4 to 7 months, so Austin's situation falls within that range. There is no cause for concern or interpretation of the finding as unusual or dangerous in this scenario.
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An adult who has gastroenteritis and is on digitalis ha lab values of: K 3.2 mEq/L, Na 136 mEq/L, Ca 8.8 mg/dl, and Cl 98 mEq/L. the nurse puts which of the following on the client's plan of care?
- A. Stop digitalis therapy
- B. Observe for trousseau's and chovestek's
- C. Avoid foods rich in potassium signs
- D. Observe for digitalis toxicity
Correct Answer: C
Rationale: The client's low potassium level (K 3.2 mEq/L) is a cause for concern, especially in a patient on digitalis therapy. Digitalis (such as digoxin) can potentiate the effects of hypokalemia, leading to an increased risk of digitalis toxicity. Therefore, in this scenario, it is important to avoid foods rich in potassium to prevent further lowering of the potassium level. It is essential to address the electrolyte imbalance promptly to prevent potential complications related to digitalis therapy.
What should be included in the plan of care for a preschool-age child who is admitted in a vasoocclusive sickle cell crisis (pain episode)?
- A. Pain management
- B. Administration of heparin
- C. Factor VIII replacement
- D. Electrolyte replacement
Correct Answer: A
Rationale: Pain management is a crucial component in the plan of care for a preschool-age child admitted with a vasoocclusive sickle cell crisis. Sickle cell disease causes blood vessels to become blocked, leading to ischemia and pain. Managing pain promptly and effectively is necessary to improve the child's comfort level and prevent complications. Pain management strategies typically involve the use of analgesic medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids, tailored to the child's age and weight. Additionally, non-pharmacological interventions like distraction techniques and positioning can help in reducing pain and promoting relaxation in children during a sickle cell crisis.
A 34 year old male client is diagnosed with encephalitis. Medication has been started for him and he is receiving nursing care. Which of the ff nursing interventions are the most critical for such a client? Choose all that apply
- A. Measuring fluid intake and output
- B. Evaluating the clients ventilation capacity and lung sound frequently
- C. Observing closely for signs of respiratory distress
- D. Administering an indwelling urethral catheter
Correct Answer: B
Rationale: B. Evaluating the client's ventilation capacity and lung sounds frequently is crucial in encephalitis because the inflammation of the brain can affect the respiratory center, leading to respiratory compromise. Any changes in ventilation capacity or abnormal lung sounds should be addressed immediately to prevent respiratory distress.
An adolescent teen has bulimia. Which assessment finding should the nurse expect to assess?
- A. Diarrhea
- B. Amenorrhea
- C. Cold intolerance
- D. Erosion of tooth enamel
Correct Answer: D
Rationale: Bulimia involves recurrent episodes of binge eating followed by compensatory behaviors such as vomiting. The frequent exposure of the teeth to stomach acid during vomiting can lead to erosion of tooth enamel. This can result in dental issues such as decay, sensitivity, and discoloration. Therefore, erosion of tooth enamel is a common assessment finding in individuals with bulimia. The other options (A. Diarrhea, B. Amenorrhea, C. Cold intolerance) are not typically associated with bulimia.
A patient has been prescribed bumetanide (Bumex) every morning for control of hypertension. Which of the ff. statements indicates correct knowledge of the treatment regimen?
- A. "I can travel to Florida and sunbathe all day."
- B. "Now I can eat whatever I want, whenever I want."
- C. "I'll take my medication in the morning, every morning."
- D. "I won't need medication once my pressure goes down."
Correct Answer: C
Rationale: The correct statement indicating the patient has a good understanding of the treatment regimen is statement C: "I'll take my medication in the morning, every morning." This statement shows that the patient acknowledges the importance of taking their prescribed bumetanide (Bumex) every morning as directed. Consistency in taking the medication as prescribed is crucial for the effective control of hypertension. Statements A and B are unrelated to the treatment regimen and do not address medication adherence. Statement D reflects a misconception that medication can be stopped once blood pressure decreases, which is inaccurate and potentially harmful.