Nokea
Dustin who was diagnosed with Hirschsprung's disease has a fever and watery explosive diarrhea. Which of the following would Nurse Joyce do first?
- A. Administer an antidiarrheal.
- B. Notify the physician immediately.
- C. Monitor the child every 30 minutes.
- D. Nothing. (These findings are common in Hirschsprung's disease.)
Correct Answer: B
Rationale: In a patient with Hirschsprung's disease presenting with fever and watery explosive diarrhea, these symptoms could indicate enterocolitis, which is a serious complication of the disease. Enterocolitis is characterized by inflammation of the intestines and can lead to significant complications if not promptly addressed. Therefore, the priority action for Nurse Joyce would be to immediately notify the physician so that appropriate interventions can be initiated promptly to manage the child's condition. Administering an antidiarrheal or monitoring the child would not be appropriate initial actions given the seriousness of the symptoms described.Ignoring these symptoms and doing nothing is also not advisable as prompt medical attention is necessary in this situation.
You may also like to solve these questions
Which of the following communication methods is not an option for a patient following laryngectomy surgery?
- A. Placing a finger over the stoma
- B. Using a picture board
- C. Using a special valve that diverts air into
- D. Learning esophageal speech the oesophagus
Correct Answer: B
Rationale: Following laryngectomy surgery, the larynx (voice box) is removed, making it impossible for the patient to produce sound for speech. The options listed are alternative communication methods for patients post-surgery, except for using a picture board. Placing a finger over the stoma can help redirect air for speech, using a special valve can help divert air for speech as well, and learning esophageal speech involves speaking by swallowing air into the esophagus and then releasing it to create sound. Picture boards are not a common method of communication for patients following laryngectomy surgery.
The nurse is conducting a staff in-service on childhood-acquired heart diseases. Which is a major clinical manifestation of rheumatic fever?
- A. Polyarthritis
- B. Osler nodes
- C. Janeway spots
- D. Splinter hemorrhages of distal third of nails
Correct Answer: A
Rationale: Rheumatic fever is a systemic inflammatory condition that can develop as a complication of untreated or inadequately treated streptococcal infections, such as strep throat. One of the major clinical manifestations of rheumatic fever is polyarthritis, which is characterized by inflammation and pain in multiple joints. It typically involves large joints like the knees, ankles, elbows, and wrists. Polyarthritis in rheumatic fever is migratory in nature, meaning the joint pain shifts from one joint to another over a period of time. Other common clinical manifestations of rheumatic fever include carditis (inflammation of the heart), chorea (involuntary movements), subcutaneous nodules, and erythema marginatum (rash).
A patient is hospitalized following a stroke. Three days after admission, the patient is able to converse clearly with the nurse during the morning assessment. Early in the afternoon, the patient's daughter runs out of the room and says, "My mother can't talk. Somebody help!" Which response by the nurse is best?
- A. Explain to the daughter that this is not uncommon, esp. in the afternoon when the patient is tired from the morning care activities.
- B. Do a quick assessment to confirm the change in the patient's status, then notify the RN or physician.
- C. Call the speech therapist to come and to do a comprehensive speech assessment.
- D. Show the daughter how to do the speech exercises with her mother that were provided by the therapist
Correct Answer: B
Rationale: The best response by the nurse in this situation would be to do a quick assessment to confirm the change in the patient's status and then notify the registered nurse (RN) or physician. It is essential for the healthcare team to promptly assess and address any sudden changes in a stroke patient's condition, such as the sudden inability to speak. This could indicate a serious issue that requires immediate attention and intervention. By quickly assessing the patient's status and notifying the appropriate healthcare provider, the nurse can ensure that the patient receives the necessary care and interventions in a timely manner.
Patients with lymphoma are at risk for infection. Which of the ff. activities increases this risk?
- A. Going to church
- B. Cleaning the house
- C. Taking a walk outside
- D. Watching television
Correct Answer: C
Rationale: Patients with lymphoma are at higher risk for infections because their immune system is often compromised due to the disease itself or treatment such as chemotherapy. Going outside for a walk exposes the patient to various environmental factors including pathogens, bacteria, and viruses that can increase the risk of infections. In contrast, going to church, cleaning the house, and watching television do not necessarily pose the same level of risk for infection as being outside in the open air. It is therefore important for patients with lymphoma to avoid unnecessary exposure to potential sources of infection to reduce their risk of developing infections.
Burns are commonly seen in child abuse. Approximately 10% of children hospitalized with burns are victims of abuse. Of the following, inflicted burn can be MOST commonly the result of
- A. contact with hot iron
- B. contact with radiators
- C. cigarette application
- D. scalding injuries
Correct Answer: D
Rationale: Scalding injuries, often caused by hot liquids, are the most common type of inflicted burns in child abuse due to their accessibility and ease of use.