Nokea
The laboratory results of a patient with disseminated intravascular coagulation are likely to include:
- A. decreased levels of fibrin split products.
- B. increased levels of fibrinogen.
- C. increased platelet counts.
- D. prolonged prothrombin and partial thromboplastin times.
Correct Answer: D
Rationale: DIC leads to prolonged clotting times due to consumption of clotting factors and platelets.
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Molly, with suspected rheumatic fever, is admitted to the pediatric unit. When obtaining the child's history, the nurseconsiders which information to be most important?
- A. A fever that started 3 days ago
- B. Lack of interest in food
- C. A recent episode of pharyngitis
- D. Vomiting for 2 days
Correct Answer: C
Rationale: A recent episode of pharyngitis is most important when obtaining the history of a child suspected of having rheumatic fever because rheumatic fever often develops as a complication of inadequately treated streptococcal pharyngitis. It is crucial to determine if there was a recent streptococcal infection to assess the likelihood of rheumatic fever developing. The other symptoms mentioned, such as fever, lack of interest in food, and vomiting, are important as well, but the connection with the recent episode of pharyngitis is more specifically related to the potential development of rheumatic fever in this case.
When assessing a female adolescent for scoliosis, what should the nurse ask the client to do?
- A. Bend forward at the waist with arms hanging freely.
- B. Lie flat on the floor and extend her legs straight from the trunk.
- C. Sit in a chair while lifting her feet and legs to a right angle with the trunk.
- D. Stand against a wall while pressing the length of her back against the wall.
Correct Answer: A
Rationale: When assessing a female adolescent for scoliosis, the nurse should ask the client to bend forward at the waist with arms hanging freely. This Adams forward bend test allows the nurse to evaluate the spine for any asymmetry, curvature, or rib hump that may indicate scoliosis. By observing the alignment of the spine while the client is in a forward bent position, the nurse can gather important information to determine if further evaluation or referral to a healthcare provider is necessary.
The home health nurse asks a child's mother many questions as part of the assessment. The mother answers many questions, then stops and says, "I don't know why you ask me all this. Who gets to know this information?" The nurse should take which action?
- A. Determine why the mother is so suspicious.
- B. Determine what the mother does not want to tell.
- C. Explain who will have access to the information.
- D. Explain that everything is confidential and that no one else will know what is said.
Correct Answer: C
Rationale: The correct action for the nurse to take in this situation is to explain who will have access to the information. This can help build trust with the child's mother and alleviate any concerns she may have about the confidentiality of the information shared during the assessment. By explaining clearly who will have access to the information and how it will be used, the nurse can address the mother's concerns and ensure that she feels comfortable sharing necessary information for the child's care. This open communication is essential in building a supportive and trusting relationship between the nurse and the child's mother.
What is cellulitis often caused by?
- A. Herpes zoster
- B. Candida albicans
- C. Human papillomavirus
- D. Streptococcus or Staphylococcus organisms
Correct Answer: D
Rationale: Cellulitis is a common skin infection that is often caused by bacteria, primarily Streptococcus or Staphylococcus organisms. These bacteria typically enter the skin through a crack or break, such as a cut, insect bite, or scratch. Once inside the skin, they can cause inflammation and infection, leading to symptoms such as redness, warmth, swelling, and tenderness in the affected area. Prompt treatment with antibiotics is essential to clear the infection and prevent complications.
Which of the ff nursing interventions should a nurse perform to relieve tachycardia that may develop in a client with myocarditis from hypoxemia?
- A. Maintain the client on bed rest c.Elevate the clients head
- B. Administer a prescribed anti pyretic
- C. Administer supplemental oxygen
Correct Answer: C
Rationale: Administering supplemental oxygen is the most appropriate nursing intervention to relieve tachycardia that may develop in a client with myocarditis from hypoxemia. Myocarditis can lead to decreased oxygen delivery to the tissues, which may result in tachycardia as the body tries to compensate for the lack of oxygen. Providing supplemental oxygen will help increase oxygen levels in the blood, improving tissue perfusion and thus reducing the tachycardia. This intervention aims to address the underlying cause of the tachycardia in this situation.