Nokea
The child who helps to undress, puts 3 words together (subject, verb, object), and handles a spoon well has an age around
- A. 15 mo
- B. 18 mo
- C. 24 mo
- D. 30 mo
Correct Answer: C
Rationale: These milestones are typically achieved around 24 months.
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To prevent leakage of fluid in the thoracic cavity, how will you position the client after thoracentesis?
- A. Place flat in bed
- B. Turn on the affected side
- C. Turn on the unaffected side
- D. On bed rest SENSORY DISORDERS
Correct Answer: C
Rationale: After thoracentesis, it is important to position the client on the unaffected side to prevent leakage of fluid into the thoracic cavity. Placing the client on the unaffected side helps to promote proper drainage and reduce the risk of complications such as pneumothorax or fluid leakage. This position also allows for adequate lung expansion and facilitates proper re-expansion of the lung on the side where the fluid was removed. It is essential to follow this positioning to optimize outcomes and minimize risks associated with the procedure.
Victorio is being managed for diarrhea. Which outcome indictes that fluid resuscitation is successful?
- A. he passess formed stools at regular intervals
- B. he reports a decrease in stool frequency and liquidity
- C. he exhibits frim skin turgor
- D. he no longer experiences perianal burning
Correct Answer: B
Rationale: The outcome that indicates successful fluid resuscitation in managing diarrhea is when the patient reports a decrease in stool frequency and liquidity. This is because diarrhea is characterized by an increase in stool frequency and liquidity due to the body's attempt to expel irritants or infections. By successfully resuscitating with fluids, the goal is to rehydrate the body and restore electrolyte balance, which should lead to a decrease in stool frequency and formation of more solid stools. This improvement in stool consistency and frequency is a clear indicator that the fluid resuscitation has been effective in treating the diarrhea. Therefore, option B is the correct choice for the outcome indicating successful fluid resuscitation in this scenario.
Which client statement would indicate to the nurse that the client with polycythemia vera is in need further of instruction?
- A. I'll be flying overseas to see my son and grandchildren for the holidays
- B. I plan to do my leg exercises at least three times a week
- C. I'm going to be walking in the mall everyday to build up my strength
- D. At night when I sleep, I like to use two pillows to raise my head up CARING FOR CLIENTS FOR DISORDERS OF THE LYMPHATIC SYSTEM
Correct Answer: A
Rationale: Clients with polycythemia vera are at an increased risk for developing blood clots due to the increased thickness of their blood. Flying long distances, especially overseas, can further increase this risk. Therefore, traveling long distances by plane can be dangerous for clients with polycythemia vera. The nurse should provide instructions to the client regarding the importance of discussing travel plans with their healthcare provider to ensure appropriate measures are in place to minimize the risk of blood clots.
Biopsy is not usually performed for a child with suspicion of Wilms tumor EXCEPT
- A. age of 2-3 year
- B. signs of inflammation or infection
- C. significant lymph node enlargement radiologically
- D. intratumoral calcification radiologically
Correct Answer: E
Rationale: Presence of intratumoral calcifications may warrant biopsy to rule out other diagnoses.
A one-month-old patient, who has developmental dysplasia of the hip, is placed in a hip spica cast. The patient's mother expresses the desire to continue breastfeeding. What is the pediatric nurse's best response?
- A. After breastfeeding, hold your baby upright for 45 minutes.
- B. Due to the weight of the cast, breastfeeding is not encouraged. I recommend that you bottle-feed.
- C. Breastfeeding can continue without significant changes; ensure proper positioning to accommodate the cast.
- D. none of the above.
Correct Answer: C
Rationale: Breastfeeding can continue even with a hip spica cast, but proper positioning is essential to ensure comfort for both the infant and the mother.