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Latasha, age 8 years, is being admitted to the hospital from the emergency department with an injury from falling off her bicycle. Which will help her most in her adjustment to the hospital?
- A. Explain hospital schedules to her, such as mealtimes.
- B. Use terms such as "honey" and "dear" to show a caring attitude.
- C. Explain when parents can visit and why siblings cannot come to see her.
- D. Orient her parents, because she is young, to her room and hospital facility.
Correct Answer: A
Rationale: Explaining hospital schedules to Latasha, such as mealtimes, will help her most in adjusting to the hospital environment. Providing her with a sense of routine and structure can help reduce her anxiety and uncertainty during her stay. By knowing when things like meals will happen, Latasha can feel more in control of her surroundings and what to expect, which can be comforting for a child in a new and potentially scary situation like being in the hospital.
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Which of the following would the nurse use to document a finding that the patient's ear is draining?
- A. Otorrhea
- B. Otalgia
- C. Ototoxic
- D. Tinnitus
Correct Answer: A
Rationale: Otorrhea is the medical term used to describe drainage from the ear. It is a finding that indicates the ear is draining fluid, which can be a sign of infection or other underlying issues. Otalgia refers to ear pain, ototoxic refers to substances that can damage the ear, and tinnitus refers to ringing in the ears. Therefore, otorrhea is the most appropriate term to document the finding of a draining ear.
Nearly all cervical carcinomas contain human papillomavirus (HPV). Which of the following types is never associated with such malignancy?
- A. type6
- B. type 16
- C. type 18
- D. type 31
Correct Answer: A
Rationale: HPV type 6 is typically associated with low-grade lesions and genital warts, not cervical carcinoma.
A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. While an airway is being established, the nurse should prepare which medication for immediate administration?
- A. Diphenhydramine (Benadryl)
- B. Dobutamine (Dobutarex)
- C. Epinephrine (Adrenalin)
- D. Calcium chloride (calcium chloride)
Correct Answer: C
Rationale: In the management of anaphylaxis, the immediate medication of choice for administration is epinephrine. Epinephrine is a potent vasoconstrictor and bronchodilator which helps restore blood pressure and open up the airways during an anaphylactic reaction. It is the first-line treatment to reverse the potentially life-threatening effects of an allergic reaction. Other medications, like diphenhydramine or dobutamine, may be used as adjuncts later in the treatment, but epinephrine is crucial for immediate administration to stabilize the child's condition.
A child has a postoperative appendectomy incision covered by a dressing. The nurse has just completed a prescribed dressing change for this child. Which description is an accurate documentation of this procedure?
- A. Dressing change to appendectomy incision completed, child tolerated procedure well, parent present
- B. No complications noted during dressing change to appendectomy incision
- C. Appendectomy incision non-reddened, sutures intact, no drainage noted on old dressing, new dressing applied, procedure tolerated well by child
- D. No changes to appendectomy incisional area, dressing changed, child complained of pain during procedure, new dressing clean, dry and intact
Correct Answer: C
Rationale: Option C provides a thorough and accurate documentation of the dressing change procedure for the postoperative appendectomy incision. This documentation includes essential details such as the condition of the incision site (non-reddened, sutures intact, no drainage noted on old dressing), the action taken (new dressing applied), and the outcome (procedure tolerated well by the child). It covers all the necessary aspects of the dressing change procedure and clearly indicates the status of the incision site before and after the intervention. Options A, B, and D do not provide as comprehensive and detailed information about the dressing change procedure and its outcomes, making option C the most appropriate choice for accurate documentation.
A patient tells his nurse that he has delayed having TURP because he is afraid it will affect his sexual function. Which response by the nurse is most appropriate?
- A. "Don't worry about sterility; sperm production is not affected by this surgery."
- B. "Would you like some information about implants used for impotence?"
- C. "This type of surgery rarely affects the ability to have an erection or ejaculation."
- D. "There are many methods of sexual expression that are alternatives to sexual intercourse."
Correct Answer: C
Rationale: The most appropriate response by the nurse is option C, "This type of surgery rarely affects the ability to have an erection or ejaculation." This response is accurate and provides reassurance to the patient while acknowledging his concerns. Transurethral resection of the prostate (TURP) is a common procedure for managing benign prostatic hyperplasia (BPH), and it typically does not have a significant impact on sexual function. By providing this information, the nurse can help alleviate the patient's fears and encourage him to proceed with the necessary treatment.