Nokea
The mother of a 9-month-old who was diagnosed with respiratory syncytial virus (RSV) yesterday calls the clinic to inquire if it will be all right to take her infant to the first birthday party of a friend's child the following day. What response should the nurse provide this mother?
- A. The child can be around other children but should wear a mask at all times.
- B. The child will no longer be contagious, no need to take any further precautions.
- C. Make sure there are no children under the age of 6 months around the infected child.
- D. Do not expose other children. RSV is very contagious even without direct oral contact.
Correct Answer: D
Rationale: The correct answer is D: Do not expose other children. RSV is very contagious even without direct oral contact.
Rationale: RSV is highly contagious and can spread through respiratory droplets, making it important to prevent exposing other children to the virus. Even without direct oral contact, the virus can be transmitted. Therefore, it is crucial to avoid putting other children at risk of contracting RSV.
Summary of other choices:
A: Wearing a mask may not be practical for an infant and may not provide sufficient protection against RSV transmission.
B: RSV can still be contagious for several days after symptoms appear, so the child may still be able to spread the virus.
C: While avoiding infants under 6 months can be a good precaution, all children should be protected from exposure to RSV due to its high contagiousness.
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During an admission physical assessment, the nurse is examining a newborn who is small for gestational age (SGA). Which finding should the nurse report immediately to the pediatric healthcare provider?
- A. Heel stick glucose of 65 mg/dL.
- B. Head circumference of 35 cm (14 inches).
- C. Widened, tense, bulging fontanel.
- D. High-pitched shrill cry.
Correct Answer: C
Rationale: The correct answer is C: Widened, tense, bulging fontanel. This finding is concerning as it can indicate increased intracranial pressure, potentially leading to serious complications in a newborn. The fontanel should be flat or slightly depressed, not bulging. Immediate reporting is necessary for timely intervention.
Incorrect choices:
A: Heel stick glucose of 65 mg/dL is slightly low but not an immediate concern; can be managed with feeding.
B: Head circumference of 35 cm is within the normal range for a newborn and does not require immediate action.
D: High-pitched shrill cry can be a sign of distress but not as urgent as a bulging fontanel in this context.
A 60-year-old male client is admitted to the hospital with the complaint of right knee pain for the past week. His right knee and calf are warm and edematous. He has a history of diabetes and arthritis. Which neurological assessment action should the nurse perform for this client?
- A. Glasgow Coma Scale
- B. Assess pulses, paresthesia, and paralysis distal to the right knee
- C. Assess pulses, paresthesia, and paralysis proximal to the right knee
- D. Optic nerve using an ophthalmoscope
Correct Answer: B
Rationale: The correct answer is B: Assess pulses, paresthesia, and paralysis distal to the right knee. This is the appropriate action because the client presents with warm, edematous right knee and calf, indicating a potential vascular issue like deep vein thrombosis (DVT). Assessing pulses, paresthesia, and paralysis distal to the right knee helps evaluate circulation and nerve function, crucial in identifying complications of DVT. Glasgow Coma Scale (A) is used to assess consciousness, not relevant in this case. Assessing proximal pulses, paresthesia, and paralysis (C) may not provide accurate information about circulation distal to the knee. Evaluating the optic nerve (D) using an ophthalmoscope is unrelated to the client's presenting symptoms and medical history.
The client with newly diagnosed osteoporosis is being taught by the nurse about dietary modifications. Which instruction should the nurse include?
- A. Increase your intake of high-calcium foods.
- B. Limit your intake of vitamin D-rich foods.
- C. Avoid foods high in phosphorus.
- D. Increase your intake of high-sodium foods.
Correct Answer: A
Rationale: The correct answer is A: Increase your intake of high-calcium foods. Osteoporosis is a condition characterized by low bone density, and calcium is essential for bone health. Increasing calcium intake can help strengthen bones and prevent further bone loss. Foods high in calcium, such as dairy products, leafy green vegetables, and fortified foods, are beneficial for individuals with osteoporosis.
Summary of other choices:
B: Limiting intake of vitamin D-rich foods is not advised, as vitamin D plays a crucial role in calcium absorption and bone health.
C: Avoiding foods high in phosphorus is not necessary, as phosphorus is also important for bone health and overall body function.
D: Increasing intake of high-sodium foods is not recommended, as high sodium intake can lead to calcium loss from the bones, worsening osteoporosis.
A client with myelogenous leukemia is receiving an autologous bone marrow transplantation (BMT). What is the priority intervention that the nurse should implement when the bone marrow is repopulating?
- A. Administer sargramostim (Leukine, Prokine).
- B. Infuse PRBC and platelet transfusions.
- C. Give parenteral prophylactic antibiotics.
- D. Maintain a protective isolation environment.
Correct Answer: D
Rationale: The correct answer is D: Maintain a protective isolation environment. During bone marrow repopulation after transplantation, the client is at high risk of infection due to compromised immune function. By maintaining a protective isolation environment, the nurse can minimize the risk of exposure to pathogens that could lead to infections. This intervention helps prevent potential complications and supports the client's recovery.
Rationale for other choices:
A: Administering sargramostim may enhance white blood cell production but does not directly address the risk of infection during bone marrow repopulation.
B: Infusing PRBC and platelet transfusions may be necessary for managing anemia and thrombocytopenia but does not address the priority of infection prevention.
C: Giving prophylactic antibiotics may be beneficial in some cases, but maintaining a protective isolation environment is the priority to reduce the risk of infection in this immunocompromised client.
A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse?
- A. Is unable to feel sensation in the arms and hands.
- B. Has flaccid upper and lower extremities.
- C. Blood pressure is 110/70 and the apical pulse is 68.
- D. Respirations are shallow, labored, and 14 breaths/minute.
Correct Answer: D
Rationale: The correct answer is D because shallow, labored respirations at 14 breaths/minute indicate potential respiratory distress in a client with a C-5 spinal cord injury. This level of injury compromises the function of the diaphragm and intercostal muscles, leading to impaired respiratory effort. Immediate intervention is crucial to prevent respiratory failure and subsequent complications. Choices A and B are common findings in clients with spinal cord injuries and do not require immediate intervention. Choice C indicates stable vital signs within normal range, which do not necessitate immediate action.