Nokea
Children with severe traumatic brain injury (TBI) may experience autonomic dysfunction characterized by all the following EXCEPT
- A. elevated temperature
- B. elevated heart rate
- C. elevated respiratory rate
- D. lowered blood pressure
Correct Answer: D
Rationale: Autonomic dysfunction in TBI typically involves elevated temperature, heart rate, and respiratory rate due to dysregulation of the autonomic nervous system. Lowered blood pressure is less common and may indicate hypovolemia or other conditions rather than autonomic dysfunction.
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Chemotherapy has a major role in many childhood CNS tumors. In which of the following tumors is chemotherapy not effective?
- A. pilocytic astrocytoma
- B. craniopharyngioma
- C. pineoblastoma
- D. supratentorial primitive neuroectodermal tumors (SPNETs)
Correct Answer: A
Rationale: Pilocytic astrocytomas are generally low-grade and less responsive to chemotherapy compared to other listed tumors.
While caring for a patient who is hospitalized for acute gastroenteritis and dehydration, the pediatric nurse notes that the patient's parent keeps packets of herbs by the patient's bedside. Suspecting that the parent may be administering the herbs to the patient, the nurse's first action is to:
- A. ask the parent in a nonjudgmental manner about the herbs.
- B. coordinate a nursing care conference to discuss the patient's plan of care.
- C. discuss the risks of using alternative therapies with the parent.
- D. refer the family to a social worker for possible nonadherence with the healthcare regimen.
Correct Answer: A
Rationale: A nonjudgmental approach encourages open communication and allows the nurse to assess the situation appropriately.
An adult suffered 2nd and third degree burns over 20% of hid body 2 days ago. What is the best way to assess the client's fluid balance?
- A. Maintain strict records of intake and output
- B. Monitor skin turgor
- C. Weigh the client daily
- D. Check for edema
Correct Answer: A
Rationale: Maintaining strict records of intake and output is the best way to assess the client's fluid balance in this situation. Severe burns can lead to fluid loss, which can result in dehydration and other complications. By carefully monitoring the amount of fluid the client is taking in (intake) and the amount of fluid being eliminated from the body (output), healthcare providers can assess the client's fluid balance and make necessary adjustments to prevent dehydration or fluid overload. This approach provides accurate and specific information to guide fluid management and ensure optimal recovery for the client with burns. Monitoring skin turgor, daily weight, and checking for edema are also important measures, but maintaining strict records of intake and output is the most direct and effective method for assessing fluid balance in a client with burns.
Which is the most critical physiologic change required of the newborn?
- A. Closure of fetal shunts in the heart
- B. Stabilization of fluid and electrolytes
- C. Body-temperature maintenance
- D. Onset of breathing
Correct Answer: D
Rationale: The most critical physiologic change required of the newborn is the onset of breathing. Prior to birth, the fetus receives oxygen from the mother's blood through the placenta. However, once the newborn is delivered, it needs to begin breathing on its own to support oxygen exchange and remove carbon dioxide from the body. The respiratory system must transition from a fluid-filled state in the womb to an air-filled state outside the womb. The onset of breathing is essential for the newborn's survival and initiates the process of oxygenation of tissues and removal of carbon dioxide, which are vital for metabolism and overall physiological functioning. While closure of fetal shunts, stabilization of fluid and electrolytes, and body-temperature maintenance are also important changes that occur in the newborn, the onset of breathing is the most critical to ensure proper oxygenation of the body's tissues.
At health fair, an oncology nurse answers questions about risk factors for various types of cancer. One person with a family history of colon cancer asks the nurse to identify risk factors for this type of cancer. The nurse should identify:
- A. Smoking
- B. Obesity
- C. Heavy alcohol consumption
- D. Saccharin consumption
Correct Answer: B
Rationale: Obesity is a known risk factor for colon cancer. Studies have shown that individuals who are obese have an increased risk of developing colon cancer compared to those who are of normal weight. The excess fat tissue, particularly around the abdomen, can lead to chronic inflammation and hormonal changes in the body, which can contribute to the development of cancer cells. It is essential for individuals with a family history of colon cancer to be mindful of maintaining a healthy weight as part of their overall cancer prevention strategies. Smoking, heavy alcohol consumption, and saccharin consumption are not identified as primary risk factors for colon cancer.