In preparing a preschool-aged patient for an injection, the most appropriate nursing intervention is to:
- A. allow the patient to administer an injection to a doll.
- B. arrange for the patient to watch a peer receive an injection.
- C. have the parents explain the process to the patient.
- D. suggest diversionary activities like singing.
Correct Answer: A
Rationale: Allowing the child to practice on a doll can help reduce anxiety and prepare them for the procedure.
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Which of the following signs indicates to the nurse that digoxin (Lanoxin) has been effective for a patient?
- A. Urine output decreases
- B. Heart rate higher than 95
- C. Urine output increases
- D. Heart rate lower than 50
Correct Answer: C
Rationale: Digoxin is a medication commonly used to treat heart failure and certain types of irregular heart rhythms. One of the therapeutic effects of digoxin is an improvement in cardiac output, leading to better tissue perfusion. As the heart's pumping ability improves, blood flow to the kidneys also increases, resulting in an increase in urine output. Therefore, an increase in urine output is a positive indication that digoxin is effective for the patient. Monitoring urine output can be a valuable way for nurses to assess the response to digoxin therapy and the overall cardiac function of the patient.
The BEST implication of a 6-month-old baby's visuomotor coordination is
- A. voluntary release of objects
- B. comparison ability of small objects
- C. increasing ability to explore objects
- D. autonomy of actions
Correct Answer: A
Rationale: Voluntary release is a key milestone in visuomotor coordination at this age.
Which of the following is the most important assessment during the acute stage of an unconscious patient like Mr. Franco?
- A. Level of awareness and response to pain
- B. Papillary reflexes and response to sensory stimuli
- C. Coherence and sense of hearing
- D. Patency of airway and adequacy of respiration
Correct Answer: D
Rationale: In the acute stage of an unconscious patient like Mr. Franco, the most critical assessment is ensuring the patency of the airway and evaluating the adequacy of respiration. Maintaining a clear airway is essential to ensure that oxygen can reach the lungs and be circulated to vital organs. Without proper airway management, a patient's condition can quickly deteriorate due to hypoxia, leading to severe complications or even death. Therefore, assessing and securing the airway is the priority in the initial management of an unconscious patient to maintain adequate oxygenation and ventilation. Monitoring the respiration rate, depth, and effort is crucial to identify any signs of respiratory distress or failure that require immediate intervention. Once the airway and breathing are addressed, further assessments related to neurological function and sensory responses can be conducted.
The first permanent tooth to erupt is
- A. central incisor at 6 yr
- B. molar at 6 yr
- C. premolar lower canine at 6-7 yr
- D. upper canine at 6-7 yr
Correct Answer: B
Rationale: The first permanent molar typically erupts around 6 years.
Which best describes acute glomerulonephritis?
- A. Occurs after a urinary tract infection
- B. Occurs after a streptococcal infection
- C. Associated with renal vascular disorders
- D. Associated with structural anomalies of genitourinary tract
Correct Answer: B
Rationale: Acute glomerulonephritis is commonly associated with a preceding streptococcal infection, particularly Group A beta-hemolytic streptococcal infection such as strep throat or impetigo. The infection triggers an abnormal immune response leading to inflammation of the glomeruli in the kidneys. This inflammation impairs the kidneys' ability to filter waste and excess fluids from the blood, resulting in symptoms such as hematuria (blood in urine), proteinuria (protein in urine), hypertension, and edema. Other causes such as renal vascular disorders, structural anomalies of the genitourinary tract, or urinary tract infections are not typically linked to acute glomerulonephritis.