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Mrs. Adams is scheduled for an intravemous pyelogram (IVP). Nurse Aura wpould be most concerned if the patient makes which of the following comments or statements?
- A. "I take Senokot (laxative) daily."
- B. "I often feel like my bladder is full even after voiding."
- C. "My whole face turns red when I eat mussels."
- D. "I experience headaches every 2 weeks."
Correct Answer: A
Rationale: Nurse Aura would be most concerned about the patient's statement regarding taking Senokot daily because laxatives can affect kidney function and urine production, which are important considerations during an intravenous pyelogram (IVP). Laxatives can lead to dehydration and electrolyte imbalances, which may affect the results and safety of the IVP procedure. It is crucial for the patient to disclose any medications or substances they are taking that could impact kidney function or urine production prior to undergoing the IVP. The other statements are not directly related to the IVP procedure or potential complications.
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What is an appropriate nursing intervention to minimize separation anxiety in a hospitalized toddler?
- A. Provide for privacy
- B. Encourage parents to room in
- C. Explain procedures and routines
- D. Encourage contact with children the same age
Correct Answer: B
Rationale: Encouraging parents to room in with the hospitalized toddler is an appropriate nursing intervention to minimize separation anxiety. This allows the child to maintain a sense of security and familiarity by having their primary caregivers close by. Having parents present can provide comfort, reassurance, and emotional support for the child during their hospital stay, which can help alleviate separation anxiety. Additionally, parents can continue to provide their usual care and routines for the child, further promoting a sense of stability and security.
Which of the ff factors makes it important for the nurse to provide special care to older clients with an immune system disorder?
- A. Age-related changes
- B. Use of multiple drugs (Polypharmacy)
- C. Poor diet
- D. Reduced activity levels
Correct Answer: A
Rationale: Age-related changes contribute significantly to the vulnerability of older clients with an immune system disorder. As people age, their immune system undergoes various alterations that can compromise its effectiveness in fighting off infections and diseases. These changes include thymic involution (decrease in thymus size and function), decrease in T-cell production, impaired immune response to infections, and decline in overall immune function. Older individuals are more susceptible to infections due to these age-related changes, which makes it essential for nurses to provide special care tailored to their specific needs. By understanding and considering these age-related immune system changes, nurses can develop appropriate care plans to support the health and well-being of older clients with immune system disorders.
7-year-old Damon has cystitis; which of the following would Nurse Elena expect when assessing the child?
- A. Dysuria
- B. Costovertebral tenderness
- C. Flank pain
- D. High fever
Correct Answer: A
Rationale: Cystitis is inflammation of the bladder, commonly caused by a bacterial infection. In children, symptoms of cystitis often include dysuria, which is painful or difficult urination. This symptom is frequently observed in children with cystitis. Costovertebral tenderness and flank pain are more indicative of kidney involvement (such as in pyelonephritis) rather than just bladder inflammation like in cystitis. High fever may also be present in severe cases of cystitis, but dysuria is the more specific and common symptom associated with this condition in children.
A client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride (Ketalar), 60g IV. After Ketamine administration, the nurse should monitor the client for:
- A. Muscle rigidity and spasms
- B. Hiccups
- C. Extrapyramidal reactions
- D. Respiratory depression
Correct Answer: A
Rationale: Ketamine hydrochloride (Ketalar) is a dissociative anesthetic that can cause muscle rigidity and spasms as a side effect. This is known as a dose-dependent reaction to ketamine administration. Monitoring for muscle rigidity and spasms is important to ensure the client's safety and to provide appropriate management if this adverse effect occurs. It is essential for the nurse to closely observe the client for any signs of muscle rigidity and spasms after the administration of ketamine.
When teaching umbilical cord care to a new mother, the nurse would include which information?
- A. Apply peroxide to the cord with each diaper change
- B. Cover the cord with petroleum jelly after bathing
- C. Keep the cord dry and open to air
- D. Wash the cord with soap and water each day during a tub bath
Correct Answer: C
Rationale: Keeping the cord dry and open to air is the recommended practice for umbilical cord care. This helps the cord to dry out and fall off naturally. Applying substances like peroxide or petroleum jelly can create a moist environment, which can increase the risk of infection. Washing the cord with soap and water daily can also prolong the time it takes for the cord to fall off. Thus, the best approach is to simply keep the cord clean and dry, allowing it to heal and detach on its own.