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Specify 2 actions the nurse should take to address that condition.
- A. Anticipate a prescription for digoxin.
- B. Elevate the head of the bed to a 45° angle.
- C. Implement contact precautions.
- D. Provide chest physiotherapy and postural drainage.
Correct Answer: A,B
Rationale: The correct answers are A and B. A nurse should anticipate a prescription for digoxin as it is commonly prescribed for heart failure to improve heart function. Elevating the head of the bed to a 45° angle helps reduce the workload on the heart and improve respiratory function. Choice C, implementing contact precautions, is unrelated to addressing the condition. Choice D, providing chest physiotherapy and postural drainage, is not typically indicated for heart failure.
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Which of the following findings should the nurse recognize as being consistent with hyperglycemia?
- A. Sweating
- B. Tremors
- C. Pallor
- D. Thirst
Correct Answer: D
Rationale: The correct answer is D: Thirst. Hyperglycemia results in elevated blood sugar levels, leading to increased osmolality and dehydration, triggering thirst as the body attempts to dilute the blood. Sweating (A), tremors (B), and pallor (C) are not typically associated with hyperglycemia. Sweating is more commonly seen in hypoglycemia, tremors can be a sign of low blood sugar, and pallor is not a direct symptom of high blood sugar levels.
Which of the following findings should the nurse identify as a manifestation of scabies?
- A. Scaly lesions on the inner thighs
- B. Rash with red macular lesions on the scalp
- C. Bull's eye edematous area on the groin
- D. Maculopapular skin burrows on the hand
Correct Answer: D
Rationale: The correct answer is D: Maculopapular skin burrows on the hand. Scabies is caused by the Sarcoptes scabiei mite, which burrows into the skin, causing characteristic burrows that appear as thin, wavy, and slightly raised grayish-white or skin-colored lines. These burrows are commonly found on the hands, fingers, wrists, and interdigital spaces. Scaly lesions on the inner thighs (A) are more indicative of fungal infections. Rash with red macular lesions on the scalp (B) is more suggestive of conditions like seborrheic dermatitis or psoriasis. A bull's eye edematous area on the groin (C) is more characteristic of Lyme disease. In summary, the presence of maculopapular skin burrows on the hand is a key manifestation of scabies, differentiating it from the other options provided.
Which of the following findings should indicate to the nurse that treatment has been effective?
- A. Odorless urine
- B. No report of pain with voiding
- C. Urine output 256 mL over 8 hours
- D. Temperature 37.2° C (99° F)
Correct Answer: C
Rationale: The correct answer is C: Urine output 256 mL over 8 hours. This finding indicates effective treatment as it shows adequate kidney function and hydration status. Normal urine output is 30-50 mL/hr, so 256 mL over 8 hours is within the expected range.
A: Odorless urine is a general indicator of hydration but not a definitive sign of treatment effectiveness.
B: No report of pain with voiding is subjective and may not always reflect treatment effectiveness.
D: Temperature within normal range is a good sign, but it does not directly indicate treatment effectiveness related to the urinary system.
Which of the following findings indicates proper functioning of the child's trigeminal nerve?
- A. The child maintains balance when standing with eyes closed.
- B. The child exhibits a gag reflex when stimulated with a tongue blade.
- C. The child correctly identifies specific scents.
- D. The child has symmetrical jaw strength when biting down.
Correct Answer: D
Rationale: The correct answer is D because symmetrical jaw strength when biting down indicates proper functioning of the trigeminal nerve, which controls the muscles of mastication. Choice A relates to the vestibular system, not the trigeminal nerve. Choice B involves the glossopharyngeal and vagus nerves. Choice C is related to the olfactory nerve.
Which of the following reactions is an age-appropriate response to death?
- A. The child views the sibling's death as permanent.
- B. The child is curious about what happened to the sibling's body.
- C. The child can give a logical explanation for the sibling's death.
- D. The child feels responsible for the sibling's death.
Correct Answer: B
Rationale: The correct answer is B because it reflects a common and age-appropriate response to death in children. Curiosity about what happened to the body is natural as children try to make sense of the concept of death. It shows a child's attempt to understand the physical aspect of death without fully grasping its emotional implications. Choices A, C, and D are incorrect. A is incorrect because children often struggle with understanding death as permanent. C is incorrect because logical explanations for death usually come later in development. D is incorrect because children typically do not feel responsible for a sibling's death at a young age.