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Matthew, age 18 months, has just been admitted with croup. His parent is tearful and tells the nurse, "This is all my fault. I should have taken him to the doctor sooner so he wouldn't have to be here." Which is appropriate in the care plan for this parent who is experiencing guilt?
- A. Clarify misconception about the illness.
- B. Explain to the parent that the illness is not serious.
- C. Encourage the parent to maintain a sense of control.
- D. Assess further why the parent has excessive guilt feelings.
Correct Answer: A
Rationale: In this situation, it is important to clarify the parent's misconception about the illness. By providing information about croup, the nurse can help the parent understand that seeking medical care promptly is essential in managing the condition but that it is not solely the parent's fault. This can help alleviate the parent's guilt and provide reassurance that they are doing their best for their child. It is essential to provide education and support to empower the parent in caring for their child effectively.
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A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. A well-informed new graduate would know the greatest likelihood of an acute hemolytic reaction would occur when giving:
- A. A-positive blood to an A-negative client
- B. O-positive blood to an A-positive client
- C. O-negative blood to an O-positive client
- D. B-positive blood to an AB-positive client
Correct Answer: B
Rationale: The greatest likelihood of an acute hemolytic reaction occurs when there is mismatch in the ABO blood group system, specifically when the recipient's plasma contains antibodies against the donor's red blood cells. In this scenario, giving O-positive blood to an A-positive client presents the highest risk because the A-positive client has anti-B antibodies in their plasma, which can attack the B antigens present on the O-positive donor red blood cells. This mismatch can lead to rapid destruction of the transfused red blood cells, causing an acute hemolytic reaction. It is crucial to ensure ABO compatibility to prevent such life-threatening reactions during blood product transfusions.
Nurse Karen is caring for a client with chronic renal failure. Which is a correct intervention for hyperkalemia?
- A. assess patient for fever and chest pain
- B. assess patient for muscle weakness, diarrhea and ECG changes
- C. encourage compliance with fluid restriction
- D. prepare patient for cardiac ultrasound
Correct Answer: B
Rationale: Hyperkalemia is a common complication in patients with chronic renal failure due to the kidneys' inability to excrete potassium efficiently. The correct intervention for hyperkalemia includes assessing the patient for muscle weakness, diarrhea, and ECG changes. Muscle weakness is a common symptom of hyperkalemia due to its effects on neuromuscular function. Diarrhea can lead to potassium loss from the gastrointestinal tract, helping to lower potassium levels. ECG changes are essential to monitor in hyperkalemia as high potassium levels can result in life-threatening cardiac arrhythmias. By identifying these signs and symptoms early, appropriate interventions can be initiated promptly, such as administering medications to lower potassium levels or adjusting the patient's diet to limit potassium intake.
The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
- A. Active exercise
- B. Use of tilt board
- C. Deep massage
- D. Proper positioning
Correct Answer: D
Rationale: Proper positioning is crucial in preventing the development of contractures in patients with spasticity of the lower extremities. Contractures can result from prolonged positioning in a way that shortens the muscle-tendon unit. By ensuring proper positioning, the nurse can help maintain the muscles and joints in a neutral and extended position, minimizing the risk of contractures. This may involve positioning supports such as pillows, splints, or footboards to keep the limbs in an optimal position.
Nursing interventions for a patient with a diagnosis of hyponatremia includes all of the following except:
- A. Assessing for symptoms of nausea and malaise
- B. Encouraging the intake of low-sodium liquids, such as coffee or tea
- C. Monitoring neurological status
- D. Restricting tap water intake
Correct Answer: B
Rationale: Hyponatremia is a condition characterized by low levels of sodium in the blood. Encouraging the intake of low-sodium liquids, such as coffee or tea, can further dilute the sodium levels in the body and worsen the condition. Instead, it is important to restrict fluid intake and focus on providing appropriate electrolyte replacement. Monitoring the patient's neurological status is crucial as severe hyponatremia can lead to neurological symptoms such as confusion, seizures, and coma. Assessing for symptoms like nausea and malaise helps in understanding the patient's condition. Restricting tap water intake is also necessary to help manage hyponatremia by preventing further dilution of sodium levels.
A patient asks how to avoid lung cancer. The following are risk factors, except:
- A. Exposure to passive smoke
- B. Crowded living conditions
- C. Air pollution
- D. Diet low in fruits and vegetables
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.