Nokea
For the first 72 hours thyroidectomy surgery, the nurse would assess the client for Chvostek's sign and Trousseau's sign because they indicate which of the following?
- A. Hypocalcamia
- B. hypokalemia
- C. Hypercalcemia
- D. Hyperkalemia
Correct Answer: A
Rationale: Chvostek's sign and Trousseau's sign are both clinical manifestations of hypocalcemia, which is a common complication following thyroidectomy surgery.
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A client who has been taking prednisone to treat lupus erythematosus has discontinued the medication because of lack of funds to buy the drug. When the nurse becomes aware of the situation, which assessment is most important for the nurse to make first?
- A. breath sounds
- B. blood pressure
- C. capillary refill
- D. butterfly rash
Correct Answer: B
Rationale: The most important assessment for the nurse to make first in this situation is the client's blood pressure. Abrupt discontinuation of prednisone, especially in a client with lupus erythematosus, can lead to adrenal insufficiency or an Addisonian crisis. Addisonian crisis can present with symptoms such as severe hypotension, fatigue, weakness, and even shock. Therefore, monitoring the client's blood pressure is crucial to assess for signs of adrenal insufficiency and to intervene promptly if needed. Once blood pressure is assessed, the nurse can then proceed to assess other parameters such as breath sounds, capillary refill, and the presence of a butterfly rash.
Which of the following is the appropriate nursing diagnosis?
- A. Fluid volume deficit R/T furrow tongue
- B. Fluid volume deficit R/T uncontrolled vomiting
- C. Dehydration R/T subnormal body temperature
- D. Dehydration R/T incessant vomiting
Correct Answer: B
Rationale: The appropriate nursing diagnosis is Fluid volume deficit R/T uncontrolled vomiting. This diagnosis is the most specific and directly related to the issue of vomiting causing a loss of fluids, leading to a deficit in fluid volume. Uncontrolled vomiting can result in a significant loss of fluids and electrolytes, which can lead to dehydration. It is important to address the root cause of the fluid volume deficit, which in this case is the uncontrolled vomiting. The other options may not directly address the primary issue of fluid loss due to vomiting.
Which is the causative agent of scarlet fever?
- A. Enteroviruses
- B. Corynebacterium organisms
- C. Scarlet fever virus
- D. Group A b-hemolytic streptococci (GABHS)
Correct Answer: D
Rationale: Scarlet fever is caused by Group Aß-hemolytic streptococci (GABHS), particularly Streptococcus pyogenes. This bacteria produces erythrogenic exotoxins that cause the characteristic rash seen in scarlet fever. These toxins also contribute to the other symptoms associated with scarlet fever, such as high fever, sore throat, and a red, bumpy tongue (strawberry tongue). Therefore, the correct causative agent of scarlet fever is Group Aß-hemolytic streptococci (GABHS).
The nurse has been caring for a newborn who just died. The parents are present but say they are "afraid" to hold the dead newborn. Which is the most appropriate nursing intervention?
- A. Tell them there is nothing to fear.
- B. Insist that they hold newborn "one last time."
- C. Respect their wishes and release body to morgue.
- D. Keep newborn's body available for a few hours in case they change their minds.
Correct Answer: D
Rationale: The most appropriate nursing intervention in this situation is to keep the newborn's body available for a few hours in case the parents change their minds. It is important to respect the parents' feelings and fears while also providing them with the opportunity to hold their child if they decide to do so later on. By keeping the newborn's body available, the parents can have the time and space they need to process their emotions and make a decision that feels right for them. This approach supports the parents' autonomy and allows them to grieve in a way that is meaningful to them.
Which behaviors by the nurse indicate a therapeutic relationship with children and families? (Select all that apply.)
- A. Spending off-duty time with children and families
- B. Asking questions if families are not participating in the care
- C. Clarifying information for families
- D. Buying toys for a hospitalized child
Correct Answer: B
Rationale: Asking questions if families are not participating in the care is a behavior that indicates a therapeutic relationship with children and families. It shows the nurse's concern and interest in understanding the family's perspectives and addressing any barriers to participation.