Nokea
For which of the following adverse effects should the nurse monitor?
- A. Prolonged wound healing
- B. Nausea
- C. Stevens-Johnson syndrome
- D. Renal failure
Correct Answer: B
Rationale: The correct answer is B: Nausea. The nurse should monitor for nausea as it is a common adverse effect of many medications and can impact the patient's overall well-being. Nausea can lead to decreased appetite, dehydration, and noncompliance with medications. Prolonged wound healing (A) is a potential adverse effect but is not as common or immediate as nausea. Stevens-Johnson syndrome (C) is a severe and life-threatening skin reaction that is rare and not typically monitored by nurses. Renal failure (D) is a serious adverse effect but may not be directly related to all medications.
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Which of the following actions should the nurse take?
- A. Administer chlorothiazide.
- B. Hold the child down.
- C. Place the child in a prone position.
- D. Time the episode.
Correct Answer: D
Rationale: The correct action is D: Time the episode. By timing the episode, the nurse can gather important data to assess the duration and severity of the situation, aiding in diagnosis and treatment planning. Administering chlorothiazide (A) without assessing the situation first could be harmful. Holding the child down (B) may escalate the situation and cause distress. Placing the child in a prone position (C) could worsen their condition. Timing the episode (D) is essential for accurate evaluation.
Which of the following instructions should the nurse include in the teaching?
- A. Wash the child's hair with shampoo containing ketoconazole.
- B. Treat everyone who came into close contact with the child.
- C. Apply petroleum jelly to the affected areas.
- D. Soak combs and brushes in boiling water for 10 min.
Correct Answer: B
Rationale: The correct answer is B: Treat everyone who came into close contact with the child. This is important in preventing the spread of contagious conditions such as lice or scabies. Treating close contacts helps eliminate the source of reinfestation.
A: Washing the child's hair with ketoconazole shampoo may be helpful for treating specific conditions but does not address preventing spread to others.
C: Applying petroleum jelly to affected areas may soothe symptoms but does not prevent transmission to others.
D: Soaking combs and brushes in boiling water is a good practice for cleaning but does not address treating close contacts.
Which of the following actions should the nurse take first?
- A. Observe the child's throat with a flashlight.
- B. Give the child small sips of water.
- C. Administer an analgesic.
- D. Offer the child an ice collar.
Correct Answer: A
Rationale: The correct answer is A: Observe the child's throat with a flashlight. This is the first action the nurse should take as it helps assess for any signs of inflammation, infection, or obstruction in the throat, which could be causing the child's symptoms. By observing the throat, the nurse can gather important information to guide further interventions.
Choice B: Giving the child small sips of water can be important but should come after assessing the throat to ensure it is safe to swallow. Choice C: Administering an analgesic should be based on the assessment findings, not the first action. Choice D: Offering an ice collar is not indicated until the cause of the symptoms is identified.
Which of the following findings should the nurse identify as a manifestation of severe dehydration?
- A. Capillary refill time 3 seconds
- B. Sunken anterior fontanel
- C. Weight loss of 5%
- D. Produces tears when crying
Correct Answer: B
Rationale: The correct answer is B: Sunken anterior fontanel. This finding is indicative of severe dehydration in infants, as it suggests significant fluid loss and decreased tissue turgor. A sunken fontanel is a late sign of dehydration. Choice A is incorrect as a capillary refill time of 3 seconds is within normal limits. Choice C may be seen in mild to moderate dehydration, but severe dehydration would involve a greater weight loss. Choice D is not specific to dehydration, as tear production can still occur even in cases of dehydration.
What is a 1-year-old with history of UTIs and diagnosed with vesicoureteral reflux s tachycardia at risk for?
- A. Nephrotic syndrome
- B. Renal Scarring
- C. Polycystic kidney
- D. Acute glomerulonephritis
- E. Pyclonephritis
Correct Answer: B,E
Rationale: The correct answers for a 1-year-old with history of UTIs and diagnosed with vesicoureteral reflux at risk for are B: Renal Scarring and E: Pyelonephritis. Vesicoureteral reflux increases the risk of recurrent UTIs, leading to pyelonephritis. Renal scarring can result from repeated pyelonephritis episodes. Nephrotic syndrome (A) is not typically associated with UTIs or reflux. Polycystic kidney (C) is a congenital condition, not related to the scenario. Acute glomerulonephritis (D) is usually caused by post-streptococcal infection, not UTIs.