Nokea
Regarding ECG in infancy
- A. T Wave inversion present
- B. PR interval is < 0.16 s
- C. P wave is < 3mm tall
- D. QRS represent ventricular depolarization
Correct Answer: B
Rationale: In infants, the PR interval is shorter than in adults (< 0.16 seconds).
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As part of the treatment for heart failure, the child takes the diuretic furosemide (Lasix). As part of teaching home care, the nurse encourages the family to give the child foods such as bananas, oranges, and leafy vegetables. These foods are recommended because they are high in which nutrient?
- A. Chlorides
- B. Potassium
- C. Sodium
- D. Vitamins
Correct Answer: B
Rationale: Diuretics that work on the proximal and distal renal tubules contribute to increased losses of potassium. The child’s diet should be supplemented with this electrolyte. With this type of diuretic, potassium must be monitored and supplemented as needed.
The MOST common cyanotic congenital cardiac lesion to present in the newborn period is
- A. dextroposed heart
- B. transposition of great arteries
- C. tetralogy of Fallot
- D. truncus arteriosus
Correct Answer: B
Rationale: Transposition of the great arteries is the most common cyanotic congenital heart defect presenting in the neonatal period.
A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?
- A. Obtain oxygen saturation level
- B. Encourage incentive spirometry
- C. Assess lower extremity circulation
- D. Administer PRN oral antipyretic
Correct Answer: D
Rationale: Administering an antipyretic addresses the fever, which is a priority in this client to prevent further complications.
An older woman who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and she only eats half of the food on her meal tray. Her family expresses concern about her nutritional status. How should the nurse respond to the family's concern?
- A. Encourage the family to offer to feed the client when she does not eat her entire meal.
- B. Suggest that the family bring foods from home that the client enjoys
- C. Explain that weight loss will be reversed after the acute phase of the stroke has ended.
- D. Demonstrate the use of visual scanning during meals to the client and family.
Correct Answer: D
Rationale: Visual scanning techniques help the client become aware of the entire meal tray, improving food intake and addressing the family's concerns.
The following statements are true:
- A. Unexplained vaginal discharge in a 3-year-old might be a sign of sexual abuse
- B. Spiral fracture of femur is always non-accidental
- C. Retinal bleeding in a 3-month-old unconscious baby is a sign of 'shaken baby' syndrome
- D. Bruises on the elbows and knees in a 4-year-old are suggestive of physical abuse
Correct Answer: C
Rationale: Retinal bleeding in a 3-month-old unconscious baby is a sign of 'shaken baby' syndrome: Retinal bleeding in infants, especially with other signs of physical abuse, is a key indicator of 'shaken baby' syndrome.