Nokea
Mrs. Tan is scheduled to undergo percutaneous transluminal coronary angioplasty (PTCA). Which of the following is the priority goal for her immediately after the procedure?
- A. prevent fluid volume deficit
- B. maintain blood pressure control
- C. decrease myocardial contractility
- D. minimize dyspnea
Correct Answer: B
Rationale: Maintaining blood pressure control is the priority goal for Mrs. Tan immediately after percutaneous transluminal coronary angioplasty (PTCA). PTCA is a procedure used to open narrowed or blocked arteries in the heart. After the procedure, there is a risk of abrupt changes in blood pressure due to various factors, such as contrast dye used during the procedure, stress on the heart, and potential complications. Maintaining stable blood pressure is crucial to ensure adequate perfusion to the heart and other organs. Monitoring and controlling blood pressure help prevent further complications and promote a smooth recovery process for the patient. It is important to address this priority goal to optimize Mrs. Tan's post-procedure outcomes.
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Which should the nurse consider when preparing a school-age child and the family for heart surgery?
- A. Unfamiliar equipment should not be shown.
- B. Let the child hear the sounds of an ECG monitor.
- C. Avoid mentioning postoperative discomfort and interventions.
- D. Explain that an endotracheal tube will not be needed if the surgery goes well.
Correct Answer: B
Rationale: When preparing a school-age child and the family for heart surgery, it is essential to provide honest and age-appropriate information to help the child feel more comfortable and reduce anxiety. Letting the child hear the sounds of an ECG monitor is beneficial as it allows them to become familiar with medical equipment and procedures, making them less intimidated by the unfamiliar sounds they may encounter during and after surgery. Familiarizing the child with the sounds can also help alleviate fears and promote understanding of what is happening during the procedure. It is important to maintain open communication, address concerns, and prepare the child and family for what to expect before, during, and after surgery.
What clinical manifestation is included in toxic shock syndrome?
- A. Severe hypertension
- B. Subnormal temperature
- C. Erythematous macular rash
- D. Papular rash over extremities
Correct Answer: C
Rationale: Toxic shock syndrome is characterized by several clinical manifestations, including a diffuse erythematous macular rash. The rash typically appears early in the course of the illness and may be followed by desquamation (peeling of the skin). Other common symptoms of toxic shock syndrome include fever, hypotension, multi-organ dysfunction, headache, myalgia, and gastrointestinal symptoms. Severe hypertension and subnormal temperature are not typically associated with toxic shock syndrome. Papular rash over extremities is not a classic manifestation of toxic shock syndrome.
Samantha, age 5 years, tells the nurse that she "needs a Band-Aid" where she had an injection. Which is the best nursing action?
- A. Apply a Band-Aid.
- B. Ask her why she wants a Band-Aid.
- C. Explain why a Band-Aid is not needed.
- D. Show her that the bleeding has already stopped.
Correct Answer: C
Rationale: The best nursing action in this scenario is to explain why a Band-Aid is not needed. At 5 years old, Samantha is at an age where she can begin to understand explanations. By providing her with a simple and clear explanation, the nurse can help Samantha understand that a Band-Aid is not necessary in this situation. This also promotes education and helps Samantha learn about wound healing and appropriate care. It is important to involve the child in the decision-making process and provide education to foster their understanding of their own health.
A client receives a sealed radiation implant to treat cervical cancer. When caring for this client, the nurse should:
- A. Consider the client's urine, feces, and vomitus to be highly radioactive
- B. Consider the client to be radioactive for 10 days after implant removal
- C. Allow soiled linens to remain in the room until after the client is discharged
- D. Maintain the client on complete bed rest with bathroom privileges only
Correct Answer: B
Rationale: When caring for a client who has received a sealed radiation implant to treat cancer, it is important to consider the client to be radioactive for a certain period of time. Typically, the client is considered radioactive for about 10 days after the implant is removed. During this time, precautions should be taken to limit exposure to radiation, including following the principles of time, distance, and shielding. It is important for healthcare providers to wear appropriate protective gear when caring for the client and to limit the time spent in close proximity to the client. After the radioactive period has passed, the client will no longer be considered radioactive, and standard precautions can be followed.
Childhood primary brain stem tumors are a heterogeneous group of tumors; the outcome usually depends on the tumor location. Which tumor, depending on the site of tumor, carries the worst prognosis?
- A. focal dorsally exophytic
- B. cervicomedullary diffuse intrinsic
- C. none of the above
- D. diffuse intrinsic
Correct Answer: D
Rationale: Diffuse intrinsic pontine gliomas (DIPG) have the worst prognosis among brainstem tumors.