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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.
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A nurse is assigned to four children of different ages. In which age group should the nurse understand that body integrity is a concern? TestBankWorld.org
- A. Toddler
- B. Preschooler
- C. School-age child
- D. Adolescent
Correct Answer: D
Rationale: Body integrity becomes a concern in adolescence, which is the period of development marked by rapid physical changes and self-awareness. Adolescents may experience body image issues, peer pressure, and the desire to conform to societal standards, which can lead to behaviors that compromise their body integrity, such as risky behaviors, eating disorders, self-harm, or seeking cosmetic procedures. By understanding the concerns surrounding body integrity in adolescents, the nurse can provide appropriate support, education, and guidance to promote healthy body image and self-esteem.
The nurse is helping parents achieve a more nutritionally adequate vegetarian diet for their child. Which is most likely lacking in their particular diet?
- A. Fat
- B. Protein
- C. Vitamins C and A
- D. Complete protein
Correct Answer: C
Rationale: A vegetarian diet can provide adequate amounts of protein, fat, and even complete protein if well-balanced. However, certain essential nutrients like vitamins C and A are more commonly found in higher concentrations in animal-based products. Therefore, in a vegetarian diet, particularly if not carefully planned, there may be a potential lack of these specific vitamins. It is important for the nurse to educate the parents on alternative plant-based sources of vitamins C and A to ensure their child's nutritional requirements are met.
A nurse is teaching a parent about introduction of solid foods into an infant's diet. Which should the nurse include in the teaching session? (Select all that apply.)
- A. Solid food introduction can be started at 2 months of age.
- B. Rice cereal is introduced first.
- C. Begin the introduction of solid foods by mixing with formula in the bottle.
- D. Introduce egg white in small quantities (1 tsp) toward the end of the first year.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following tests is most effective in diagnosing hemophilia?
- A. Bleeding time
- B. Complete blood count (CBC)
- C. Partial thromboplastin time (PTT)
- D. Platelet count
Correct Answer: C
Rationale: Partial thromboplastin time (PTT) is the most effective test in diagnosing hemophilia. Hemophilia is a genetic disorder that results in prolonged clotting times due to deficiencies in specific clotting factors, such as factor VIII (hemophilia A) or factor IX (hemophilia B). PTT is a screening test that evaluates the intrinsic pathway of coagulation and helps identify deficiencies in clotting factors. In patients with hemophilia, PTT is typically prolonged due to the reduced activity of the deficient clotting factor. Therefore, measuring PTT can aid in the diagnosis of hemophilia by assessing the clotting function and identifying specific clotting factor deficiencies. Other tests like bleeding time, CBC, and platelet count are important in evaluating overall bleeding tendencies, but they are not as specific for diagnosing hemophilia as the PTT test.
Parents of a newborn ask the nurse why vitamin K is being administered. The nurse accurately responds by explaining phytonadione (vitamin K) is administered to the newborn to:
- A. prevent bleeding.
- B. enhance immune response.
- C. prevent bacterial infection.
- D. maintain nutritional status.
Correct Answer: A
Rationale: Vitamin K is essential for the production of clotting factors in the liver. Newborns have lower levels of vitamin K and may not have a fully functioning clotting system, putting them at risk for bleeding disorders such as vitamin K deficiency bleeding (VKDB). Administering vitamin K to newborns helps prevent these bleeding issues and ensures proper clotting function. It does not have a direct effect on enhancing the immune response, preventing bacterial infections, or maintaining nutritional status, as its primary function in this context is to prevent bleeding disorders.