Nokea
The nurse assesses a client being treated for Herpes Zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment? (Select all that apply)
- A. Skin integrity
- B. Functional ability
- C. Heart sounds
- D. Pain scale
Correct Answer: A
Rationale: These assessments help determine the effectiveness of treatment in managing pain, skin lesions, and the client's ability to perform daily activities.
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Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux?
- A. Teach the client to elevate the head of the bed on blocks
- B. Remind the client to avoid high-fiber foods
- C. Encourage the client to lie down and rest after meals
- D. Instruct the client to use antacids only as a last resort
Correct Answer: A
Rationale: Elevating the head of the bed on blocks helps reduce reflux of stomach acid into the esophagus, improving symptoms of gastroesophageal reflux disease.
Surgical repair of VSD should be considered at the time of diagnosis
- A. small supracristal VSD
- B. VSD with heart failure
- C. hemodynamically restrictive VSD
- D. significant VSD
Correct Answer: B
Rationale: Significant or symptomatic VSDs warrant early surgical intervention.
The following are strongly associated with Kawasaki disease EXCEPT
- A. duration of fever of >16 days
- B. first-degree heart block
- C. male gender
- D. age of <1 year
Correct Answer: B
Rationale: First-degree heart block is less commonly associated with Kawasaki disease compared to other factors.
Features differentiating renal tubular acidosis type II from type I include:
- A. Increased anion gap
- B. Nephrocalcinosis
- C. Urinary pH can be lowered < 5.5 in ammonium chloride loading test in type I
- D. Aminoaciduria
Correct Answer: C
Rationale: In type I renal tubular acidosis, urinary pH can be lowered below 5.5 during an ammonium chloride loading test, unlike in type II.
Which intervention should the nurse plan to decrease cardiac demands in an infant with congestive heart disease (CHD)?
- A. Organize nursing activities to allow for uninterrupted sleep.
- B. Allow the infant to sleep through feedings during the night.
- C. Wait for the infant to cry to show definite signs of hunger.
- D. Discourage parents from rocking the infant.
Correct Answer: A
Rationale: The infant requires rest and conservation of energy for feeding. Every effort is made to organize nursing activities to allow for uninterrupted periods of sleep. Whenever possible, parents are encouraged to stay with their infant to provide the holding, rocking, and cuddling that help children sleep more soundly. To minimize disturbing the infant, changing bed linens and complete bathing are done only when necessary. Feeding is planned to accommodate the infant’s sleep and wake patterns. The child is fed at the first sign of hunger, such as when sucking on fists, rather than waiting until he or she cries for a bottle because the stress of crying exhausts the limited energy supply. Because infants with CHD tire easily and may sleep through feedings, smaller feedings every 3 hours may be helpful.