Nokea
Nurse Nancy is assessing a child with pyloric stenosis; she is likely to note which of the following?
- A. "Currant jelly" stools
- B. Regurgitation
- C. Steatorrhea
- D. Projectile vomiting
Correct Answer: D
Rationale: Pyloric stenosis is a condition in infants where there is a tightening of the muscle at the outlet of the stomach, causing obstruction of food passage into the small intestine. One of the hallmark symptoms of pyloric stenosis is projectile vomiting, in which the vomit is forceful and shoots out a significant distance. This distinguishes it from regular regurgitation or spitting up, which are more common in infants for other reasons. Nurse Nancy would likely note this symptom while assessing a child with pyloric stenosis.
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A 5-year-old child, recently diagnosed with ileocecal Burkitt lymphoma; lab investigations reveal: serum uric acid 12 mg/dl, serum sodium, 145 meq/dl; serum potassium, 4.5 meq/dl; serum phosphate 4.4 meq/dl; serum calcium, 8.9 mg/dl; blood urea, 22 mg/dl; serum creatinine, 0.8 mg/dl. Of the following, the MOST effective treatment is
- A. excessive hydration
- B. sodium bicarbonate
- C. xanthine oxidase inhibitor
- D. recombinant urate oxidase
Correct Answer: D
Rationale: Recombinant urate oxidase (rasburicase) effectively lowers uric acid levels in cases of tumor lysis syndrome.
Which is an effective strategy to reduce the stress of burn dressing procedures?
- A. Give the child as many choices as possible.
- B. Reassure the child that dressing changes are not painful.
- C. Explain to the child why analgesics cannot be used.
- D. Encourage the child to master stress with controlled passivity.
Correct Answer: A
Rationale: Giving the child as many choices as possible is an effective strategy to reduce the stress of burn dressing procedures. Allowing the child to have some control over the situation can help them feel more empowered and less anxious. By giving choices, such as letting the child choose the order in which things are done or the type of dressing used, the child is more likely to feel a sense of autonomy and reduced stress during the procedure. This approach can help the child cope better with the dressing changes and make the experience more manageable for them.
A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of:
- A. Severe hypotension
- B. Profound neuromuscular irritability
- C. Excessive thirst
- D. Acute gastritis
Correct Answer: B
Rationale: Hypoparathyroidism is a condition characterized by decreased levels of parathyroid hormone, which can lead to low levels of calcium in the blood (hypocalcemia). Profound neuromuscular irritability is a significant complication of hypocalcemia and is a key concern for clients with hypoparathyroidism. Symptoms can include muscle cramps, tetany, seizures, and decreased cardiac contractility. Monitoring for neuromuscular irritability and promptly addressing low calcium levels are essential in the care of clients with hypoparathyroidism.
Which of the ff diets does the nurse recommend for clients with hypertension under the physicians guidance?
- A. The Food Guide Pyramid
- B. The South Beach Diet
- C. The Step One Diet
- D. The Dash diet
Correct Answer: D
Rationale: The Dietary Approaches to Stop Hypertension (DASH) diet is recommended by healthcare professionals, including nurses, for clients with hypertension. This diet emphasizes consuming fruits, vegetables, whole grains, lean proteins, and low-fat dairy products while limiting sodium, saturated fats, and cholesterol. These dietary components are known to help lower blood pressure and improve overall health. The DASH diet has been proven effective in numerous studies and is endorsed by organizations like the American Heart Association for managing hypertension. It is important for clients to follow the DASH diet under the guidance of a physician to ensure it is tailored to their individual needs and health status.
A spica cast was put on Baby Betty after an unfortunate incident to immobilize her hips and thighs; which of the following is the priority nursing action immediately after application?
- A. Keep the cast dry and clean.
- B. Cover the perineal area.
- C. Elevate the cast.
- D. Perform neurovascular checks.
Correct Answer: D
Rationale: Performing neurovascular checks is the priority nursing action immediately after applying a spica cast on Baby Betty. A spica cast is used to immobilize the hips and thighs, which can affect circulation and nerve function in the lower extremities. Neurovascular checks involve assessing the circulation, sensation, and movement of the affected limb to ensure there are no signs of impaired circulation or nerve damage. It is crucial to monitor for any signs of compartment syndrome, such as pain, numbness, tingling, or decreased pulse, which could indicate a vascular compromise. Timely identification of any neurovascular compromise is essential to prevent complications and ensure the baby's safety and well-being.