Nokea
The home care nurse visits a child diagnosed with scarlet fever who is being treated with penicillin G potassium. The mother tells the nurse that the child has only voided a small amount of tea-colored urine since the previous day. The mother also reports that the child's appetite has decreased and that the child's face was swollen this morning. How should the nurse interpret these new signs/symptoms?
- A. Nothing to be concerned about
- B. Signs/symptoms of acute glomerulonephritis
- C. Signs/symptoms of the normal progression of scarlet fever
- D. Symptoms of an allergic reaction to penicillin G potassium
Correct Answer: B
Rationale: Scarlet fever is an infectious and communicable disease caused by group A beta-hemolytic streptococci. The signs/symptoms identified in the question indicate acute glomerulonephritis, indicative of nephrotoxicity. These signs/symptoms are not normal and should not be ignored. Although the child is receiving penicillin G potassium, these are not signs/symptoms of an allergic reaction.
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The client diagnosed with prostatitis asks the nurse, 'Why do I need to take a stool softener? The problem is with my urine, not my bowels!' Which response should the nurse make to the client?
- A. This is a standard medication prescription for anyone with a urine problem.
- B. This will keep the bowel free of feces, which helps decrease the swelling inside.
- C. Being constipated puts you at more risk for developing complications of prostatitis.
- D. This will help you prevent constipation because straining is painful with prostatitis.
Correct Answer: D
Rationale: Stool softeners prevent constipation, which can cause painful straining in clients with prostatitis, exacerbating discomfort. They are not standard for all urinary issues, do not directly reduce swelling, and constipation does not cause complications of prostatitis.
The nurse is percussing the anterior thorax and the abdomen for tones and expects to note dullness in which anatomic location? (Refer to figure.)
- A. Location 1
- B. Location 2
- C. Location 3
- D. Location 4
Correct Answer: C
Rationale: Percussion involves tapping the body with the fingertips to set the underlying structures in motion and thus produce a sound. Dullness will be noted over the liver, located in the upper right quadrant of the abdomen and beneath the lower ribs on the right side. Tympany is the most common percussion tone heard in the abdomen and is caused by the presence of gas. Resonance is the percussion tone heard between the ribs.
A toddler with suspected conjunctivitis is crying and refuses to sit still during the eye examination. Which is the most appropriate statement for the nurse to make to the child?
- A. Would you like to see my flashlight?
- B. Don't be scared, the light won't hurt you.
- C. If you will sit still, the exam will be over soon.
- D. I know you are upset. We can do this exam later.
Correct Answer: A
Rationale: Engaging the toddler by offering to show the flashlight reduces fear and encourages cooperation, suitable for this developmental stage. Other options either dismiss feelings, demand compliance, or delay the necessary exam inappropriately.
The nurse is caring for a client diagnosed with end-stage renal disease. What areas are appropriate to assess to determine the client's wishes for end-of-life nursing care?
- A. Preferred place for death
- B. Client expectations for nursing care
- C. Financial responsibilities for the funeral
- D. Where the funeral and burial will take place
- E. Use of and the level of life-sustaining measures
- F. Expectations regarding pain control and symptom management
Correct Answer: A,B,E,F
Rationale: The nurse must assess the client's wishes for end-of-life nursing care because these can influence how the nurse sets priorities for planning and implementing care. End-of-life assessment related to nursing care should include the preferred place for death, client expectations for nursing care, the use of and the level of life-sustaining measures, and expectations regarding pain control and symptom management. Financial responsibilities for the funeral and where the funeral and burial will take place are issues that the client may want to discuss, but they are unrelated to nursing care.
The nurse is teaching health education classes to a group of expectant parents, and the topic is preventing cognitive impairment caused by congenital hypothyroidism. What should the nurse tell the parents is the most effective means of promoting early intervention?
- A. Vitamin intake
- B. Neonatal screening
- C. Adequate protein intake
- D. Limiting alcohol consumption
Correct Answer: B
Rationale: Congenital hypothyroidism is a common preventable cause of cognitive impairment. Neonatal screening is the only means of early diagnosis followed by intervention and the subsequent prevention of cognitive impairment. Newborn infants are screened for congenital hypothyroidism before discharge from the newborn nursery and before 7 days of life. Treatment is begun immediately, if necessary. Vitamin intake and adequate protein will not specifically prevent this disorder. Alcohol consumption during pregnancy needs to be restricted rather than just limited.