Nokea
Kasabach-Merritt syndrome is characterized by all the following EXCEPT
- A. thrombocytopenia
- B. microangiopathic hemolytic anemia
- C. coagulopathy
- D. association with infantile hemangiomas
Correct Answer: D
Rationale: Kasabach-Merritt syndrome is not typically associated with hemangiomas.
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A client has undergone a nephrectomy and is placed under observation after a urethral catheter insertion. As part of the nursing care plan, the nurse records the color of drainage from each tube and catheter. Which of the ff is the reason for this?
- A. To restore and maintain intravascular volume
- B. To provide a means for further comparison and evaluation
- C. To avoid interference with wound drainage
- D. To prevent pain related to obstruction
Correct Answer: B
Rationale: Recording the color of drainage from each tube and catheter is crucial in the nursing care plan as it provides a means for further comparison and evaluation. Changes in the color of drainage can indicate potential issues such as infection, bleeding, or other complications post-surgery. By monitoring the color of drainage, the nurse can identify any abnormal changes early on and take appropriate actions to address them promptly. This practice helps in assessing the patient's condition and ensuring optimal recovery and healing after the surgery.
is a Self - Limiting disease that affects of femoral head :
- A. Coxa
- B. JRA
- C. Rickets
- D. DDH
Correct Answer: C
Rationale: Rickets is a self-limiting disease that affects the growth plates in bones, including the femoral head. It is primarily caused by a deficiency in vitamin D, which is necessary for proper bone mineralization and growth. Rickets is more common in children and can lead to weakened bones, deformities, and growth disturbances. With proper treatment and supplementation, rickets can be reversed and often resolves once the underlying vitamin D deficiency is addressed.
A Jewish client has been diagnosed with ulcerative colitis. A nursing diagnosis appropriate for a client who has ulcerative colitis is:
- A. abdominal pain related to decreased peristalsis
- B. diarrhea related to hyperosmolar intestinal contents
- C. fluid volume excess related to increase water absorption by intestinal mucosa
- D. activity intolerance related to fatigue
Correct Answer: A
Rationale: Among the given choices, the nursing diagnosis appropriate for a client with ulcerative colitis is "abdominal pain related to decreased peristalsis." Ulcerative colitis is a chronic inflammatory bowel disease that directly affects the lining of the colon and rectum, leading to symptoms such as abdominal pain, diarrhea, and bloody stool. Decreased peristalsis occurs in patients with ulcerative colitis, resulting in abdominal pain due to inflammation and irritation of the intestines. This pain is a common symptom experienced by individuals with ulcerative colitis and can significantly impact their quality of life. Therefore, addressing the client's abdominal pain is crucial in providing effective nursing care for someone diagnosed with ulcerative colitis.
The nurse is preparing an in-service education to staff about atraumatic care for pediatric patients. Which intervention should the nurse include?
- A. Prepare the child for separation from parents during hospitalization by reviewing a video.
- B. Prepare the child before any unfamiliar treatment or procedure by demonstrating on a stuffed animal.
- C. Help the child accept the loss of control associated with hospitalization.
- D. Help the child accept pain that is connected with a treatment or procedure.
Correct Answer: B
Rationale: Atraumatic care for pediatric patients aims to minimize emotional and psychological distress during hospitalization or medical procedures. Option B, preparing the child before any unfamiliar treatment or procedure by demonstrating it on a stuffed animal, is an appropriate intervention. This technique allows the child to understand what will happen, reduces fear of the unknown, and promotes a sense of control. By using a stuffed animal as a teaching tool, the nurse can provide clear information to the child in a non-threatening way, helping to alleviate anxiety and stress. This intervention encourages trust between the child and healthcare provider and promotes a positive healthcare experience for the pediatric patient.
A 4-month old infant who has a congenital heart defect develops heart failure and is exhibiting marked dyspnea at rest . The nurse is aware this finding can be attributed to:
- A. Anemia
- B. Hypovolemia
- C. Pulmonary edema
- D. Metabolic acidosis blood specimen is obtained. The child's color becomes blue and respiratory rate increases to 44 bpm. Which of the following actions would the nurse do first?
Correct Answer: C
Rationale: The nurse would first assess for an irregular heart rate and rhythm. In a 4-month old infant with a congenital heart defect experiencing marked dyspnea at rest, the sudden onset of cyanosis (blue coloration) and increased respiratory rate can indicate worsening heart failure and potential arrhythmias. Assessing for any abnormal heart rhythms is a priority to determine if immediate intervention is required to stabilize the infant's condition and prevent further deterioration.