Nokea
During the first 4 days of hospitalization, Eric, age 18 months, cried inconsolably when his parents left him, and he refused the staff's attention. Now the nurse observes that Eric appears to be "settled in" and unconcerned about seeing his parents. The nurse should interpret this as which statement?
- A. He has successfully adjusted to the hospital environment.
- B. He has transferred his trust to the nursing staff.
- C. He may be experiencing detachment, which is the third stage of separation anxiety.
- D. Because he is "at home" in the hospital now, seeing his mother frequently will only start the cycle again.
Correct Answer: A
Rationale: Eric's change in behavior from crying inconsolably and refusing staff attention to now appearing settled and unconcerned about his parents leaving indicates that he has successfully adjusted to the hospital environment. This adaptation is a positive sign that Eric has become more comfortable with his surroundings and has developed a sense of security within the hospital setting. As a result, the nurse can interpret this change as Eric successfully acclimating to his new environment.
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Which finding would you expect in a 4-week-old with biliary atresia?
- A. Abdominal distention, enlarged liver and spleen, clay-colored stools, and tea-colored urine.
- B. Abdominal distention with bruises and hematuria.
- C. Yellow sclera/skin, oily skin, and prolonged bleeding times.
- D. No manifestations until advanced disease.
Correct Answer: A
Rationale: Biliary atresia typically presents with hepatosplenomegaly, pale stools, and dark urine due to impaired bile excretion.
At what age should the nurse expect the anterior fontanel to close?
- A. 2 months
- B. 2 to 4 months
- C. 6 to 8 months
- D. 12 to 18 months
Correct Answer: D
Rationale: The nurse should expect the anterior fontanel to close between the ages of 12 to 18 months. The fontanel is the soft spot on a baby's head that allows for the growth of the skull during infancy. It is the last fontanel to close, with closure typically occurring by around 18 months of age. Monitoring the closure of the fontanel is important as it can provide valuable information about the baby's hydration status and overall development.
A nurse is admitting a child to the hospital with a diagnosis of giardiasis. Which medication should the nurse expect to be prescribed?
- A. Metronidazole (Flagyl)
- B. Amoxicillin clavulanate (Augmentin)
- C. Clarithromycin (Biaxin)
- D. Prednisone (Orapred)
Correct Answer: A
Rationale: Giardiasis is an intestinal infection caused by a protozoan parasite called Giardia lamblia. Metronidazole (Flagyl) is the drug of choice for treating giardiasis in children and adults. It is an antibiotic that is effective against a wide range of anaerobic bacteria and protozoa, including Giardia lamblia. Metronidazole works by disrupting the DNA of the parasite, leading to its death. It is usually well-tolerated and has a high cure rate for giardiasis. Amoxicillin clavulanate (Augmentin) is a combination antibiotic used to treat bacterial infections, not parasitic infections like giardiasis. Clarithromycin (Biaxin) is primarily used for treating bacterial infections, such as respiratory tract infections. Prednisone (Orapred) is a corticosteroid used to reduce
In planning safe care for the older adult, which of the ff. conditions does the nurse recognize would not cause visual problems?
- A. Glaucoma
- B. Macular degeneration
- C. Cataracts
- D. Arcus senilis
Correct Answer: D
Rationale: Arcus senilis is a condition characterized by a white or gray ring forming around the cornea and does not typically cause visual problems. It is a common and benign condition often seen in older adults. On the other hand, glaucoma, macular degeneration, and cataracts are all eye conditions that can significantly affect vision and lead to visual impairments in older adults. Therefore, in planning safe care for the older adult, the nurse should recognize that Arcus senilis would not cause visual problems unlike the other conditions mentioned.
What does nursing care of the newborn with oral candidiasis (thrush) include?
- A. Avoiding use of pacifier
- B. Removing characteristic white patches with a soft cloth
- C. Continuing medication for a prescribed number of days
- D. Applying medication to oral mucosa, being careful that none is ingested
Correct Answer: D
Rationale: Nursing care of the newborn with oral candidiasis (thrush) includes applying medication to the oral mucosa, being careful that none is ingested. This is because oral candidiasis is a fungal infection caused by Candida fungus, and treating it requires antifungal medication to effectively clear the infection. It is crucial to apply the medication directly to the affected oral mucosa to target and eliminate the fungus. Care must be taken to ensure that none of the medication is accidentally ingested by the newborn during the application process. This approach helps provide direct treatment to the affected area and promotes quicker resolution of oral thrush.