Nokea
Specify what condition the client is most likely experiencing.
- A. Pyloric stenosis
- C. Congestive heart failure
- D. Respiratory syncytial virus bronchiolitis
Correct Answer: C
Rationale: The correct answer is C: Congestive heart failure. The client is most likely experiencing Congestive heart failure due to presenting symptoms such as dyspnea, fatigue, edema, and possibly crackles on lung auscultation. These symptoms are indicative of fluid accumulation in the lungs and peripheral tissues, common in congestive heart failure. Pyloric stenosis (A) is a gastrointestinal condition, not related to the symptoms described. Respiratory syncytial virus bronchiolitis (D) typically presents with respiratory distress in infants. The other choices are omitted as they are not relevant to the symptoms described.
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The nurse should monitor the child for which of the following complications?
- A. Nuchal rigidity when standing
- B. Double vision
- C. Headache
- D. Pain in the posterior iliac crest
Correct Answer: C
Rationale: The correct answer is C: Headache. In pediatric patients, headaches can be indicative of serious underlying conditions such as meningitis or increased intracranial pressure. Monitoring for headaches is crucial for early detection and intervention. Nuchal rigidity when standing (A) is more indicative of meningitis in adults. Double vision (B) is more associated with neurological issues. Pain in the posterior iliac crest (D) is not typically a complication that requires monitoring in children.
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 is a clinical manifestation associated with this diagnosis?
- A. Tachypnea
- B. Tremors
- C. Increased appetite
- D. Bradycardia
Correct Answer: A
Rationale: The correct answer is A: Tachypnea. Tachypnea refers to rapid breathing, which is a common clinical manifestation associated with various medical conditions, including respiratory distress. In this particular diagnosis, tachypnea may indicate underlying respiratory issues or distress. Tremors (B) and increased appetite (C) are not typically associated with this diagnosis. Bradycardia (D), which is a slow heart rate, is also not a common clinical manifestation in this context.
Which of the following actions should the nurse take first?
- A. Obtain an x-ray of the child's neck.
- B. Administer intravenous antibiotics.
- C. Initiate droplet precautions.
- D. Place intubation equipment at the bedside.
Correct Answer: D
Rationale: The correct action for the nurse to take first is to place intubation equipment at the bedside (Choice D). This is crucial in case the child's condition deteriorates rapidly and respiratory support is needed. Placing the intubation equipment ensures immediate access to airway management, which takes precedence over other actions. Obtaining an x-ray may provide diagnostic information but is not as urgent as ensuring airway patency. Administering antibiotics and initiating droplet precautions (Choice C) are important but not the immediate priority in this scenario. Therefore, Choice D is the correct first action to ensure the child's safety and optimal care.
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.