Nokea
Nurse Hannah is administering a steroid to a child diagnosed with idiopathic thrombocytopenic purpura (ITP); which of the following should the nurse monitor?
- A. Infection
- B. Anemia
- C. Bleeding
- D. Bruising
Correct Answer: C
Rationale: Idiopathic thrombocytopenic purpura (ITP) is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Steroids are often prescribed to help increase platelet production in patients with ITP. Therefore, the nurse should monitor the child for signs of bleeding, such as petechiae, ecchymosis, gum bleeding, and other unusual bleeding manifestations. Monitoring for bleeding is crucial to assess the effectiveness of the steroid treatment and to prevent complications associated with ITP.
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A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement?
- A. Related to visual field deficits
- B. Related to impaired balance
- C. Related to difficulty swallowing
- D. Related to psychomotor seizures
Correct Answer: B
Rationale: A client with a cerebellar brain tumor is likely to experience impaired balance due to the location of the tumor affecting the cerebellum, which is responsible for coordinating movement and balance. Impaired balance increases the risk for falls and other injuries, making it a priority concern for the client. Therefore, adding "Related to impaired balance" to the nursing diagnosis statement would be the most appropriate choice to address the client's risk for injury in this situation.
Which of the ff is a sign or symptom of asthma?
- A. Production of abnormally thick, sticky mucus in lungs
- B. Faulty transport of sodium in lung cells
- C. Paroxysms or shortness of breath
- D. Altered electrolyte balance in the sweat glands
Correct Answer: C
Rationale: Paroxysms, or sudden attacks, of shortness of breath are a common sign or symptom of asthma. Asthma is a chronic respiratory condition characterized by inflammation and narrowing of the airways, which leads to difficulty breathing. During an asthma attack, individuals may experience sudden and severe shortness of breath, often accompanied by wheezing, coughing, and chest tightness. These paroxysms of breathlessness are a hallmark feature of asthma and indicate the presence of airway inflammation and constriction.
A one-month-old patient, who has developmental dysplasia of the hip, is placed in a hip spica cast. The patient's mother expresses the desire to continue breastfeeding. What is the pediatric nurse's best response?
- A. After breastfeeding, hold your baby upright for 45 minutes.
- B. Due to the weight of the cast, breastfeeding is not encouraged. I recommend that you bottle-feed.
- C. Breastfeeding can continue without significant changes; ensure proper positioning to accommodate the cast.
- D. none of the above.
Correct Answer: C
Rationale: Breastfeeding can continue even with a hip spica cast, but proper positioning is essential to ensure comfort for both the infant and the mother.
The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. How should this action be interpreted?
- A. Inappropriate, because of child's age
- B. A way to establish rapport
- C. Too distracting, when cooperation is important
- D. Acceptable, if there is adequate time
Correct Answer: B
Rationale: Using a simple magic trick with gauze to engage a 5-year-old child during a dressing change is a way to establish rapport. This approach can help build trust and reduce anxiety by making the procedure more engaging and less intimidating for the child. By creating a positive interaction through a fun activity, the nurse can promote cooperation and make the dressing change a smoother experience for the child. Overall, the use of a magic trick in this context is appropriate and beneficial for enhancing the child's cooperation and comfort.
Victorio is being managed for diarrhea. Which outcome indictes that fluid resuscitation is successful?
- A. he passess formed stools at regular intervals
- B. he reports a decrease in stool frequency and liquidity
- C. he exhibits frim skin turgor
- D. he no longer experiences perianal burning
Correct Answer: B
Rationale: The outcome that indicates successful fluid resuscitation in managing diarrhea is when the patient reports a decrease in stool frequency and liquidity. This is because diarrhea is characterized by an increase in stool frequency and liquidity due to the body's attempt to expel irritants or infections. By successfully resuscitating with fluids, the goal is to rehydrate the body and restore electrolyte balance, which should lead to a decrease in stool frequency and formation of more solid stools. This improvement in stool consistency and frequency is a clear indicator that the fluid resuscitation has been effective in treating the diarrhea. Therefore, option B is the correct choice for the outcome indicating successful fluid resuscitation in this scenario.