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Just as the nurse was entering the room, the patient who was sitting on his chair begins to have a seizure. Which of the following must the nurse do first?
- A. Ease the patient to the floor
- B. Insert a padded tongue depressor between his jaws
- C. Lift the patient and put him on the bed
- D. Restraint patient's body movement
Correct Answer: A
Rationale: When a patient is having a seizure, the primary goal is to keep the patient safe and prevent injury. By easing the patient to the floor, the nurse can prevent potential injury from falling. It is important to ensure there are no objects nearby that can harm the patient during the seizure. Placing something between the patient's jaws or restraining their body movements are not recommended as they can potentially harm the patient or exacerbate the seizure. Once the patient is safely on the floor, the nurse can protect the patient's head, remove any harmful objects, and monitor the seizure until it subsides.
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The twelve-year-old boy has fractured his arm because of a fall from his bike. After the injury has been casted, the nurse knows it is most important to perform all of the following assessments on the area distal to the injury except:
- A. capillary refill.
- B. radial and ulnar pulse.
- C. finger movement
- D. skin integrity
Correct Answer: B
Rationale: Assessing the radial and ulnar pulses is crucial in evaluating the circulation of blood to the hand. However, in this scenario of a fractured arm, the injury is distal to the hand (further away from the body). It is more critical to check capillary refill, finger movement, and skin integrity in the area distal to the injury to ensure there is no compromise to the blood flow, nerve function, or skin integrity following the injury. Checking the radial and ulnar pulse would be more relevant if the injury was closer to the wrist area, as it would directly impact these pulses.
A nurse is planning a teaching session for parents of a newborn who plan to bottle-feed. Which should the nurse include in the teaching session? (Select all that apply.)
- A. Limiting the feeding to 15 minutes
- B. Propping the bottle for night feedings is acceptable
- C. Proper technique for cleansing the bottles and nipples
- D. Feeding infant on alternate sides of the lap
Correct Answer: C
Rationale: Proper technique for cleansing the bottles and nipples - It is essential to educate parents on the proper technique for cleaning bottles and nipples to prevent bacteria growth and ensure the newborn's milk is not contaminated.
A 1-year-old child develops right eye ptosis, miosis, and loss of sweating; you suspect neuroblastoma. The MOST valuable investigation to confirm the diagnosis is
- A. CT scan of the neck and chest
- B. CT scan of the abdomen
- C. CT scan of the brain
- D. magnetic resonance imaging (MRI) of the brain
Correct Answer: A
Rationale: CT scan of the neck and chest can help identify a primary neuroblastoma mass in the adrenal gland or sympathetic chain.
The beta subunit of human chorionic gonadotropin (HCG) is a useful surface marker in some malignant germ cell tumors (GCTs); it is secreted by syncytiotrophoblasts. In which of the following GCTs this surface marker is characteristically elevated?
- A. teratoma
- B. germinoma
- C. endodermal sinus tumor
- D. embryonal carcinoma
Correct Answer: D
Rationale: Embryonal carcinoma is strongly associated with elevated beta-HCG levels.
What should the nurse suggest to the parents of an infant who has a prolonged need for middle-of-the-night feedings?
- A. Decrease daytime feedings.
- B. Allow child to go to sleep with a bottle.
- C. Offer last feeding as late as possible at night.
- D. Put infant to bed after asleep from rocking.
Correct Answer: C
Rationale: The nurse should suggest to the parents to offer the last feeding as late as possible at night for an infant who has a prolonged need for middle-of-the-night feedings. By ensuring that the infant gets a full feeding closer to bedtime, it can potentially help the baby stay fuller for a longer period during the night, reducing the need for frequent nighttime feedings. This approach can help the parents establish a bedtime routine that supports longer stretches of sleep for both the infant and themselves. It is important to note that decreasing daytime feedings, allowing the child to go to sleep with a bottle, and putting the infant to bed after they are already asleep from rocking are not recommended strategies for addressing prolonged middle-of-the-night feedings.