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Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse in charge detects dry mucous membranes and lethargy. What other findings suggests a fluid volume deficit?
- A. A sunken fontanel
- B. Decreased pulse rate
- C. Increased blood pressure
- D. Low urine specific gravity
Correct Answer: A
Rationale: A sunken fontanel is a classic sign of dehydration in infants. When a child is experiencing fluid volume deficit, the body's priority is to maintain blood flow to vital organs, resulting in decreased blood circulation to the skin and extremities. Consequently, decreased skin turgor and a sunken fontanel are common manifestations of dehydration. Other signs of fluid volume deficit may include dry mucous membranes, lethargy, decreased urine output, and increased heart rate.
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Joel's parents ask if-their other children will be affected by the disorder. Which of the following statements should guide the nurse in her response? a.All the girls will be normal and the other son a carrier
- A. All the girls will be carriers and one half the boys will be affected
- B. Each son has a chance of being affected and each daughter a 50% chance of being a carrier
- C. Each son has 50% chance of being affected or a carrier, and the girls will be all carriers.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A blood sample for measurement of bilirubin is required from a newborn receiving phototherapy. In what environment should this blood sample be drawn?
- A. While phototherapy lights are turned off
- B. While newborn remains under phototherapy lights
- C. When newborn is covered with a blanket
- D. When newborn has been off phototherapy for 30 to 60 minutes
Correct Answer: D
Rationale: The blood sample for measurement of bilirubin should be drawn when the newborn has been off phototherapy for 30 to 60 minutes. The reason for this is that phototherapy can alter bilirubin levels through photoisomerization, making it challenging to interpret the results accurately while the newborn is still under the lights. Allowing a period of 30 to 60 minutes for the newborn to be off phototherapy helps to ensure that the bilirubin level obtained from the blood sample reflects a more accurate baseline level. This practice helps in guiding clinical management decisions related to managing hyperbilirubinemia in newborns.
A chest radiograph film is ordered for a child with suspected cardiac problems. The child's parent asks the nurse, "What will the radiograph show about the heart?" What knowledge about the x-ray should the nurse include in the response to the parents?
- A. Bones of chest but not the heart
- B. Measurement of electrical potential generated from heart muscle
- C. Permanent record of heart size and configuration
- D. Computerized image of heart vessels and tissues
Correct Answer: C
Rationale: A chest radiograph film, commonly known as a chest X-ray, shows a permanent record of the size and configuration of the heart. It can provide information about the overall size and shape of the heart, the presence of any abnormalities (such as an enlarged heart), and the position of the heart within the chest cavity. While a chest X-ray can also show the bones of the chest, it is primarily used to visualize the heart and lungs. It does not measure electrical potential generated from heart muscle (which would be seen on an ECG) or show a computerized image of heart vessels and tissues (which would typically require more advanced imaging techniques such as a CT scan or MRI).
Which of the ff factors makes it important for the nurse to provide special care to older clients with an immune system disorder?
- A. Age-related changes
- B. Use of multiple drugs (Polypharmacy)
- C. Poor diet
- D. Reduced activity levels
Correct Answer: A
Rationale: Age-related changes contribute significantly to the vulnerability of older clients with an immune system disorder. As people age, their immune system undergoes various alterations that can compromise its effectiveness in fighting off infections and diseases. These changes include thymic involution (decrease in thymus size and function), decrease in T-cell production, impaired immune response to infections, and decline in overall immune function. Older individuals are more susceptible to infections due to these age-related changes, which makes it essential for nurses to provide special care tailored to their specific needs. By understanding and considering these age-related immune system changes, nurses can develop appropriate care plans to support the health and well-being of older clients with immune system disorders.
Which of the ff conditions is evident by persistent hoarseness?
- A. Bacterial infection
- B. Aphonia
- C. Laryngeal cancer
- D. Peritonsillar abscess
Correct Answer: C
Rationale: Persistent hoarseness is often a symptom of laryngeal cancer. Laryngeal cancer affects the voice box, leading to changes in voice quality, such as hoarseness. It is important to seek medical evaluation if hoarseness lasts for more than two weeks, as early detection and treatment of laryngeal cancer can improve outcomes. Bacterial infection, aphonia (loss of voice), and peritonsillar abscess are not typically associated with persistent hoarseness as a primary symptom.