Nokea
Nursing assessment of early evidence of septic shock in children at risk includes:
- A. Fever, tachycardia, and tachypnea
- B. Respiratory distress, cold skin, and pale extremities
- C. Elevated blood pressure, hyperventilation, and thready pulses
- D. Normal pulses, hypotension, and oliguria
Correct Answer: A
Rationale: Fever, tachycardia, and tachypnea are the classic early signs of septic shock in children. Respiratory distress, cold skin, and pale extremities are later signs of septic shock. Elevated blood pressure, hyperventilation, and thready pulses are later signs of septic shock. Normal pulses, hypotension, and oliguria are not early signs of septic shock.
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An elective saline abortion has been performed on a 3-week primigravida. Following the procedure, the nurse should be alert for which early side effect?
- A. Water satiety
- B. Thirst
- C. Edema
- D. Diabetes insipidus
Correct Answer: B
Rationale: Saline absorption into the bloodstream increases serum sodium, leading to thirst as an early side effect.
Which client clinical manifestation during a bone marrow transplantation procedure alerts the nurse to the possibility of an adverse reaction?
- A. Fever
- B. Red colored urine
- C. Hypertension
- D. Shortness of breath
Correct Answer: D
Rationale: Shortness of breath may indicate an acute transfusion reaction (e.g., TRALI) during bone marrow transplantation, requiring immediate action. Fever (A), red urine (B), and hypertension (C) are less specific or expected.
The client is admitted with a diagnosis of gestational diabetes. Which dietary recommendation is most appropriate?
- A. Low-carbohydrate,high-protein diet
- B. High-fat,low-calorie diet
- C. Low-protein,high-carbohydrate diet
- D. High-calorie,low-fat diet
Correct Answer: A
Rationale: A low-carbohydrate high-protein diet helps maintain stable blood glucose levels in gestational diabetes reducing the risk of hyperglycemia. High-fat high-carbohydrate or high-calorie diets are less suitable.
A client with a history of phenylketonuria is seen at the local family planning clinic. After completing the client's intake history, the nurse provides literature for a healthy pregnancy. Which statement indicates that the client needs further teaching?
- A. I can help control my weight by switching from sugar to Nutrasweet.
- B. I need to resume my old diet before becoming pregnant.
- C. I need to eliminate most sources of phenylalanine from my diet.
- D. Fresh fruits and raw vegetables will make excellent between-meal snacks.
Correct Answer: A
Rationale: Nutrasweet (aspartame) contains phenylalanine, which is harmful in phenylketonuria, so this statement indicates a need for further teaching.
When evaluating a client with symptoms of shock, it is important for the nurse to differentiate between neurogenic and hypovolemic shock. The symptoms of neurogenic shock differ from hypovolemic shock in that:
- A. In neurogenic shock, the skin is warm and dry
- B. In hypovolemic shock, there is a bradycardia
- C. In hypovolemic shock, capillary refill is less than 2 seconds
- D. In neurogenic shock, there is delayed capillary refill
Correct Answer: A
Rationale: Neurogenic shock is caused by injury to the cervical region, which leads to loss of sympathetic control. This loss leads to vasodilation of the vascular beds, bradycardia, and warm, dry skin. In hypovolemic shock, the client is hypotensive, tachycardiac, with cool skin and delayed capillary refill (>5 seconds).