Nokea
The basic principle of healthy sleep hygiene which is NOT included is
- A. set routine
- B. avoid stimulating activities as playing computer games
- C. makes sure child spends time outside every day
- D. gives a heavy meal within an hour of bedtime
Correct Answer: D
Rationale: Heavy meals close to bedtime disrupt sleep.
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The nurse in the postoperative unit prepares to receive a client after a balloon angioplasty of the carotid artery. Which of the ff items of priority should the nurse keep at the bedside for such client?
- A. Blood pressure apparatus
- B. IV infusion stand
- C. Call bell
- D. Endotracheal intubation
Correct Answer: A
Rationale: Having a blood pressure apparatus at the bedside is a priority for a client following a balloon angioplasty of the carotid artery. Monitoring blood pressure closely is essential to assess for any signs of complications such as bleeding or thrombosis after the procedure. Rapid identification and management of any changes in blood pressure are crucial in the immediate postoperative period to ensure the client's safety and well-being. It allows the nurse to promptly intervene if there are any signs of complications, helping to prevent further harm to the client.
Which of the following malignancies is least likely to occur in a 10-month-old infant?
- A. neuroblastoma
- B. nephroblastoma
- C. retinoblastoma
- D. hepatoblastoma
Correct Answer: D
Rationale: Hepatoblastoma is rare in infants under 1 year old, being more common in toddlers.
Which age group should the pediatric nurse recognize as being vulnerable to events that lessen their feeling of control and power?
- A. Infants
- B. Toddlers
- C. Preschoolers
- D. School-age children
Correct Answer: A
Rationale: Infants are the age group that the pediatric nurse should recognize as being vulnerable to events that lessen their feeling of control and power. Infants are entirely dependent on others for their care and are still developing their sense of self and autonomy. They are unable to communicate their needs effectively and rely on caregivers to interpret and respond to their cues. Any disruptions in routine or changes in their environment can make infants feel insecure and powerless. Therefore, the pediatric nurse should be particularly attentive to the emotional needs and sense of control of infants when providing care.
Patients are at risk for overwhelming postsplenectomy infection (OPSI) following splenectomy. Which of the ff. symptoms alerts the nurse to this possibility?
- A. Bruising around the operative site
- B. Pain
- C. Irritability
- D. Fever
Correct Answer: D
Rationale: Patients who have undergone splenectomy are at risk for overwhelming postsplenectomy infection (OPSI) due to the absence of a functioning spleen, which is important in fighting certain types of infections, especially those caused by encapsulated bacteria such as Streptococcus pneumoniae. Symptoms of OPSI can include fever, chills, weakness, and rapid breathing. Fever is a significant sign that alerts the nurse to the possibility of OPSI in a post-splenectomy patient, as it may indicate an infection that the body is struggling to fight without the spleen's immune support. This is a crucial symptom to monitor and act upon promptly to prevent serious complications in these individuals.
A 90 y.o. nursing home resident with stage 2 Alzheimer's disease is found alone and crying in the dining room. She says she lost her mother and doesn't know what to do. Which response by the nurse will help calm the resident?
- A. "Remember your mother has been dead for 30 years. You forgot again, didn't you?"
- B. "I'm sorry you lost your mother; let's go and try to find her."
- C. "Are you feeling frightened? I'm here and I will help you."
- D. "You are 90 years old. It is impossible for your mother to still be living. I know if you try, you can figure out what to do."
Correct Answer: C
Rationale: Option C, "Are you feeling frightened? I'm here and I will help you," is the most appropriate response to help calm the resident. The resident is experiencing confusion and distress, likely due to her Alzheimer's disease. Invalidating her feelings by reminding her of the reality may lead to more confusion and distress. Instead, acknowledging the resident's emotions, offering support, and reassuring her of your presence can help calm her down and provide comfort in the moment. It is important to provide emotional support and reassurance to individuals with Alzheimer's disease, rather than focusing on correcting their statements or reminding them of reality.