Nokea
José is a 4-year-old child scheduled for a cardiac catheterization. What should be included in preoperative teaching?
- A. Directed at his parents because he is too young to understand
- B. Detailed in regard to the actual procedures so he will know what to expect
- C. Done several days before the procedure so that he will be prepared
- D. Adapted to his level of development so that he can understand
Correct Answer: D
Rationale: Preoperative teaching should always be directed at the child’s stage of development. The caregivers also benefit from the same explanations. The parents may ask additional questions, which should be answered, but the child needs to receive the information based on developmental level. Preschoolers will not understand in-depth descriptions and should be prepared close to the time of the cardiac catheterization.
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Mental retardation is found in all the following:
- A. Trisomy 21
- B. Morquio syndrome
- C. Homocystinuria
- D. Ehlers-Danlos syndrome
Correct Answer: A
Rationale: Trisomy 21 (Down syndrome) is a well-known cause of mental retardation. Morquio syndrome, Homocystinuria, and Ehlers-Danlos syndrome are not typically associated with mental retardation.
A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain?
- A. What time did he take his last medications?
- B. Has his weight changed in the last several days?
- C. Is he still able to tighten his belt buckle?
- D. How many hours did he sleep last night?
Correct Answer: B
Rationale: Weight gain is a key indicator of fluid retention in heart failure, which can exacerbate symptoms.
On assessment of a child admitted with a diagnosis of Kawasaki Disease, the nurse expects to note which clinical manifestation of the acute phase of the disease?
- A. Cracked lips
- B. Normal appearance
- C. Conjuntival hyperemia
- D. Desquamation of the skin
Correct Answer: C
Rationale: Conjunctival hyperemia is a common clinical manifestation during the acute phase of Kawasaki Disease, characterized by redness of the eyes without discharge.
The nurse is assessing clients in an outpatient diabetic clinic. Which entry provides the best evidence that the client is adhering to the prescribed diabetic regimen?
- A. Hemoglobin A1C of 6.2%
- B. Fasting blood glucose of 130 mg/dL
- C. Positive urine ketones
- D. Self-reported daily blood glucose monitoring
Correct Answer: A
Rationale: A hemoglobin A1C of 6.2% indicates good glycemic control, reflecting adherence to the diabetic regimen.
Evidence of increased pulmonary flow is associated with:
- A. Coarctation of the aorta
- B. Fallot's tetralogy
- C. Pneumocystis infection
- D. Ventricular septal defect
Correct Answer: D
Rationale: A ventricular septal defect (VSD) leads to increased pulmonary blood flow due to left-to-right shunting, resulting in pulmonary congestion.