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During a routine checkup, the nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the common AIDS-related cancer?
- A. Squamous cell carcinoma
- B. Leukemia
- C. Multiple myeloma
- D. Kaposi's sarcoma
Correct Answer: D
Rationale: Kaposi's sarcoma is the most common AIDS-related cancer. It is a type of cancer that usually appears as lesions on the skin, mouth, or internal organs. Kaposi's sarcoma is caused by human herpesvirus 8 (HHV-8) and is more likely to develop in individuals with weakened immune systems, such as those with AIDS. The risk of developing Kaposi's sarcoma is higher in people with HIV/AIDS due to the weakened immune system's inability to fight off infections and certain cancers. Regular assessment for signs and symptoms of Kaposi's sarcoma is important in people living with AIDS in order to detect and treat it early.
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The nurse is caring for a child with acute renal failure. Which clinical manifestation should the nurse recognize as a sign of hyperkalemia?
- A. Dyspnea
- B. Seizure
- C. Oliguria
- D. Cardiac arrhythmia
Correct Answer: D
Rationale: Hyperkalemia is a condition characterized by elevated levels of potassium in the blood. This can have serious effects on the heart, leading to cardiac arrhythmias which can be life-threatening. In acute renal failure, the kidneys are not able to properly regulate potassium levels in the blood, leading to a potential buildup of potassium, resulting in hyperkalemia. The nurse should recognize cardiac arrhythmias as a critical sign of hyperkalemia in a child with acute renal failure and take prompt action to address this electrolyte imbalance. Dyspnea, seizure, and oliguria are not typically directly correlated with hyperkalemia.
Which of the ff symptoms should a nurse assess in a client when implementing interventions for trauma to the upper airway?
- A. Pain when talking
- B. Increased nasal swelling
- C. Burning in the throat
- D. Presence of laryngospasm INFECTIONS OF THE LOWER RESPIRATORY AIRWAY
Correct Answer: D
Rationale: When implementing interventions for trauma to the upper airway, it is crucial for the nurse to assess for the presence of laryngospasm. Laryngospasm is a sudden spasm of the vocal cords that may cause difficulty breathing and in severe cases, complete airway obstruction. It is a serious and potentially life-threatening complication that can occur following upper airway trauma. Therefore, prompt recognition and treatment of laryngospasm are essential to ensure adequate oxygenation and ventilation for the client. Pain when talking, increased nasal swelling, and burning in the throat may also be symptoms encountered in upper airway trauma, but the presence of laryngospasm signifies a more critical condition requiring immediate intervention.
What is the care priority for a newborn with bladder exstrophy and a malformed pelvis?
- A. Change the diaper frequently and assess for skin breakdown.
- B. Keep the exposed bladder open in a warm, dry environment.
- C. Offer formula for growth and fluid management.
- D. Cluster care to allow the child uninterrupted sleep and strength for upcoming surgical repair.
Correct Answer: D
Rationale: Minimizing disturbances (clustering care) helps prevent infection and allows the infant to conserve energy before surgical repair.
A nurse has been examining the vital signs of the client for the past 2 days. On a particular day, she observe a sudden change in the vital signs of the client. Which of the ff steps should the nurse take immediately?
- A. Inform the physician
- B. Change the environmental settings of the client
- C. Alter the diet intake of the client
- D. Decrease the physical activity of the client if any.
Correct Answer: A
Rationale: The nurse should immediately inform the physician about the sudden change in the client's vital signs. Sudden changes in vital signs can be indicative of a serious health issue or medical emergency that would require the expertise and intervention of a physician. Prompt communication with the physician is essential to ensure timely assessment, diagnosis, and appropriate treatment for the client. It is crucial to prioritize the client's well-being and safety in such situations, which is why informing the physician is the most appropriate and urgent step to take.
Latasha, age 8 years, is being admitted to the hospital from the emergency department with an injury from falling off her bicycle. Which will help her most in her adjustment to the hospital?
- A. Explain hospital schedules to her, such as mealtimes.
- B. Use terms such as "honey" and "dear" to show a caring attitude.
- C. Explain when parents can visit and why siblings cannot come to see her.
- D. Orient her parents, because she is young, to her room and hospital facility.
Correct Answer: A
Rationale: Explaining hospital schedules to Latasha, such as mealtimes, will help her most in adjusting to the hospital environment. Providing her with a sense of routine and structure can help reduce her anxiety and uncertainty during her stay. By knowing when things like meals will happen, Latasha can feel more in control of her surroundings and what to expect, which can be comforting for a child in a new and potentially scary situation like being in the hospital.