Nokea
The MOST likely cause of a 4-year-old boy refusing to go to bed and remaining active is
- A. thyrotoxicosis
- B. ADHD
- C. behavioral insomnia of childhood
- D. sleep-onset association disorder
Correct Answer: C
Rationale: Behavioral insomnia involves resistance to bedtime routines.
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Which is the leading cause of death after heart transplantation?
- A. Infection
- B. Rejection
- C. Cardiomyopathy
- D. Heart failure
Correct Answer: A
Rationale: Infection is the leading cause of death after heart transplantation. Following transplantation, patients are at a higher risk of infections due to the immunosuppressive medications they must take to prevent organ rejection. These medications suppress the immune system's responses, leaving the patient susceptible to various infections such as bacterial, viral, and fungal infections. Without timely diagnosis and treatment, these infections can lead to serious complications and even death in heart transplant recipients. Therefore, the careful monitoring and management of infections are crucial in post-transplant care to improve outcomes and prevent mortality.
gauge needle for drawing up medication and injecting it
- A. Inject the medication in the upper arm muscle
- B. Use a 1 inch needle to administer the medication
- C. Use the Z track technique to administer the medication
Correct Answer: B
Rationale: Using a 1 inch needle is the appropriate gauge needle for drawing up medication and injecting it. The length of the needle is important to ensure that the medication reaches the intended target area and is administered effectively. Shorter needles may not penetrate deep enough, while longer needles may increase the risk of complications such as injecting the medication into the wrong tissue or causing discomfort to the patient. Therefore, using a 1 inch needle is the correct choice for administering medication safely and accurately.
The physician orders local application of epinephrine 1:1000 solution to treat a nosebleed. The patient asks how this will help. Which of the ff. responses by the nurse is best?
- A. "It will raise you BP, which is necessary because of blood loss."
- B. "It will dilate your bronchioles and make your breathing easier."
- C. "It will help your blood to clot to reduce bleeding."
- D. "It will constrict your vessels and slow down the bleeding."
Correct Answer: D
Rationale: Epinephrine is a vasoconstrictor, which means it causes blood vessels to narrow. When applied locally to the site of a nosebleed, epinephrine constricts the blood vessels in the nose, slowing down and stopping the bleeding. By constricting the blood vessels, epinephrine helps to reduce the blood flow to the area, allowing a clot to form and stop the bleeding. This is why option D, "It will constrict your vessels and slow down the bleeding," is the best response by the nurse to explain how epinephrine will help treat a nosebleed.
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.
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.