Nokea
For a 14-month-old whose cleft palate was repaired 12 hours ago, which should be included in the plan of care?
- A. Allow familiar comfort items (e.g., favorite stuffed animal) and a 'sippy' cup (avoid suction items).
- B. Once liquids are tolerated, encourage a bland diet (e.g., soup, Jell-O, saltine crackers).
- C. Administer scheduled pain medication rather than PRN only.
- D. Use a Yankauer suction catheter to decrease aspiration risk.
Correct Answer: A
Rationale: Providing comfort items and avoiding suction items helps reduce distress and supports healing.
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the following are signs and symptoms of congenital hip dysplasia except:
- A. ortolani's click
- B. limited hip adduction.
- C. asymmetric gluteal folds.
- D. trendelenburg's while standing. 127
Correct Answer: D
Rationale: Trendelenburg's sign is not a typical sign of congenital hip dysplasia. Trendelenburg's sign indicates weakness of the hip abductor muscles and is seen when a person stands on one leg and the pelvis on the unsupported side drops. The other options are more commonly associated with congenital hip dysplasia:
The nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination:
- A. at the end of her menstrual cycle
- B. on the 1st day of the menstrual cycle
- C. on the same day each month
- D. immediately after her menstrual period
Correct Answer: C
Rationale: The nurse should advise the premenopausal woman to perform her breast self-examination on the same day each month. Regular monthly self-examination helps the woman become familiar with the normal texture and appearance of her breasts, making it easier to detect any changes or abnormalities that may indicate a problem. Performing the examination on the same day each month helps ensure consistency in timing and facilitates the woman to establish a routine for self-examination. This consistent approach increases the likelihood of detecting any changes early, which is crucial for timely medical evaluation and intervention if needed.
The following data collection findings could indicate to the nurse that the patient has a hearing loss, EXCEPT:
- A. Patient's face is relaxed during conversation.
- B. Patient speaks in a very loud voice.
- C. Patient turns toward person speaking.
- D. Patient is withdrawn.
Correct Answer: A
Rationale: A relaxed face during conversation is not typically indicative of hearing loss. In fact, individuals with hearing loss may exhibit signs such as speaking loudly (Choice B), turning toward the person speaking (Choice C), and feeling withdrawn (Choice D) due to difficulty in hearing and understanding conversations. The act of speaking loudly may be an attempt to compensate for the perceived hearing loss, while turning toward the speaker is a common strategy to better hear and lip-read. Withdrawal can result from the frustration and isolation caused by the inability to fully engage in conversations. Ultimately, a relaxed face during conversation is less likely to be a red flag for hearing loss compared to the other choices provided.
For a patient who is being discharged on digoxin, the nurse should include which of the ff. in an explanation to the patient on the signs and symptoms of digoxin toxicity?
- A. Poor appetite
- B. Halos around lights
- C. Constipation
- D. Tachycardia
Correct Answer: B
Rationale: Digoxin toxicity can manifest in various ways, but one common sign is the presence of visual disturbances such as seeing halos around lights. This is due to digoxin's effect on the optic nerve. Patients experiencing halos around lights should seek medical attention promptly as it may indicate a serious reaction to the medication. The other options (poor appetite, constipation, tachycardia) may occur with digoxin toxicity as well, but the visual disturbance of halos around lights is a classic and important sign to be aware of.
Aisa is to have blood transfusion. Which of the following problems is most likely associated with blood transfusion?
- A. Serum hepatitis
- B. Pulmonary edema
- C. Allergic response
- D. Hemolytic reaction Situation: Joel is a toddler who has classical hemophilia.
Correct Answer: D
Rationale: A hemolytic reaction is the most likely problem associated with blood transfusion. A hemolytic reaction occurs when the body's immune system attacks the transfused blood, leading to the destruction of red blood cells. This reaction can cause serious complications, including kidney damage, shock, and even death. It is crucial for healthcare providers to carefully match blood types and perform compatibility testing before administering a blood transfusion to minimize the risk of a hemolytic reaction. Serum hepatitis, pulmonary edema, and allergic responses are potential complications of blood transfusions, but hemolytic reactions pose the most immediate and severe threat to the patient's health.