During early postburn care of the child, it is essential for the nurse to closely monitor which of the following?
- A. Unburned skin
- B. Bowel elimination
- C. I.V. fluid therapy
- D. Pupillary response to light
Correct Answer: C
Rationale: I.V. fluid therapy is critical in the early postburn phase to prevent hypovolemic shock and maintain organ perfusion. Close monitoring ensures adequate resuscitation and prevents complications like over- or under-hydration.
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A 30 years old G3P2 at 28 weeks of gestation presents with severe pain in the right flank radiating to her groin. She also complaints of rigors and chills. Urine analysis reveals numerous pus cells. The most likely diagnosis is:
- A. Appendicitis.
- B. Pyelonephritis.
- C. Round ligament torsion.
- D. Meckel's diverticulum.
- E. Torsion of ovarian cyst.
Correct Answer: B
Rationale: Pyelonephritis a urinary tract infection affecting the kidneys presents with flank pain fever,chills,and pus cells in urine,as described. Appendicitis typically involves right lower quadrant pain and other options lack urinary findings or are less likely in pregnancy.
While preparing parents of a 2-day-old,bottle-feeding newborn for discharge the nurse recognizes the parents’ need for additional teaching about formula feeding. Which statement prompted the nurse’s conclusion?
- A. “We plan to clean our baby’s bottles in the dishwasher.”
- B. “Placing the formula in a bowl of warm water will warm it.”
- C. “We will put the bottle of unfinished formula in the refrigerator.”
- D. “Using our city tap water to mix the powdered formula is safe.”
Correct Answer: C
Rationale: Unfinished formula mixed with saliva should be discarded due to bacterial growth risk. Dishwasher cleaning warming in water and municipal tap water use are safe.
When preparing the adolescent for the examination, the nurse correctly explains that a specimen should be collected and sent to the laboratory. Which specimen should the nurse collect?
- A. Blood sample
- B. Urine sample
- C. Vaginal smear
- D. Biopsy of the cervix
Correct Answer: C
Rationale: A vaginal smear is appropriate for diagnosing gonorrhea in females, allowing culture or nucleic acid testing of cervical or vaginal secretions to detect Neisseria gonorrhoeae.
Which diet is most appropriate for an adolescent with oral lesions and a herpes simplex infection of the mouth secondary to acquired immunodeficiency syndrome (AIDS)?
- A. High-calorie, bland diet
- B. Soft, low-protein diet
- C. Low-residue, low-fat diet
- D. High-residue, low-cholesterol diet
Correct Answer: A
Rationale: A high-calorie, bland diet supports nutritional needs while minimizing irritation to oral lesions, appropriate for an AIDS patient with oral herpes lesions.
A primipara presents one week after delivery. She is tearful,has spells of cry and lack of appetite and sleep. What is the most likely diagnosis:
- A. Anaemia.
- B. Post-natal depression.
- C. Schizophrenia.
- D. Maniac disorders.
- E. High grade fever.
Correct Answer: B
Rationale: Post-natal depression is common in the first weeks postpartum presenting with tearfulness appetite loss and sleep disturbances. Other diagnoses are less likely without specific symptoms.