Nokea
The nurse closely monitors the temperature of a child with minimal change nephrotic syndrome. The purpose of this assessment is to detect an early sign of which possible complication?
- A. Infection
- B. Hypertension
- C. Encephalopathy
- D. Edema
Correct Answer: A
Rationale: In a child with minimal change nephrotic syndrome, the nurse closely monitors the temperature to detect an early sign of infection. Children with nephrotic syndrome are more susceptible to infections due to loss of immunoglobulins in the urine, decreased serum complement levels, and altered immune function. Monitoring the temperature is important to identify any signs of infection early, as prompt treatment is crucial in preventing complications such as sepsis.
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A patient is unable to control his bowels ff. a subarachnoid hemorrhage. Which intervention by the nurse can help reduce episodes of bowel incontinence?
- A. Ask the patient frequently if he has to have a bowel movement
- B. Place incontinence pads on the patient's bed and chair
- C. Toilet the patient according to his pre-illness schedule, whether or not he feels the urge
- D. Take care not to embarrass the patient when incontinent episode occur
Correct Answer: C
Rationale: Option C, which is to toilet the patient according to his pre-illness schedule, whether or not he feels the urge, is the best intervention by the nurse to help reduce episodes of bowel incontinence in this patient with subarachnoid hemorrhage. This strategy can help establish a routine and promote regular bowel movements, which may reduce the likelihood of bowel incontinence episodes. Asking the patient frequently if he has to have a bowel movement (Option A) may not be effective, as the patient may not always be able to accurately communicate their needs due to the underlying condition. Placing incontinence pads on the patient's bed and chair (Option B) may manage the consequences of incontinence but does not address the root cause. While taking care not to embarrass the patient when incontinent episodes occur (Option D) is important for maintaining the patient's dignity, it does not directly address the issue of reducing bowel incontinence episodes.
Which of the ff nursing interventions is required when caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion?
- A. Restrict fluid intake
- B. Ensure that the client avoids prolonged sitting
- C. Position lower extremities below level of heart
- D. Instruct the client to avoid leg exercises
Correct Answer: C
Rationale: When caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion, it is important to promote optimal blood flow to the tissues. Positioning the lower extremities below the level of the heart helps to facilitate venous return and improve circulation to the extremities. This position helps reduce the workload on the heart and promotes better perfusion to the tissues, ultimately aiding in the prevention of complications related to ineffective tissue perfusion. The other options (A. Restrict fluid intake, B. Ensure that the client avoids prolonged sitting, D. Instruct the client to avoid leg exercises) are not directly related to improving tissue perfusion and may not be appropriate interventions in this situation.
Many neuromuscular disorders can impair respiratory function. What intervention can a home care nurse recommend to help prevent complications in patients with impaired respiratory function?
- A. Antibiotics as needed
- B. Bedrest
- C. Elevate the head of bed
- D. Suction q4h
Correct Answer: C
Rationale: Elevating the head of the bed is an important intervention to help prevent complications in patients with impaired respiratory function. By elevating the head of the bed, gravity assists in improving lung expansion and ventilation, making breathing easier for the patient. This position promotes better airflow and can help reduce the risk of respiratory complications such as aspiration. It is a non-invasive and simple intervention that can be easily implemented in a home care setting to support the patient's respiratory function and overall well-being. Antibiotics, bedrest, and scheduled suctioning are not directly related to improving respiratory function in this context.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will prescribe diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client does not comply with the recommended treatment, which complication may arise?
- A. Cerebral edema
- B. Severe hyperkalemia
- C. Hypovolemic shock
- D. Tetany
Correct Answer: A
Rationale: Syndrome of inappropriate antidiuretic hormone (SIADH) is characterized by excessive release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia. If a client with SIADH does not comply with the recommended treatment of diuretic therapy and fluid/sodium restriction, there will be continued water retention, resulting in further dilution of sodium levels in the blood (hyponatremia). Severe hyponatremia can lead to cerebral edema, which is a life-threatening complication associated with neurological symptoms such as headache, confusion, seizures, and potentially coma. Therefore, it is important for the client to follow the prescribed treatment to prevent the development of cerebral edema and other serious complications.
Which is the major cause of death for children older than 1 year?
- A. Cancer
- B. Heart disease
- C. Unintentional injuries
- D. Congenital anomalies
Correct Answer: C
Rationale: Unintentional injuries are the major cause of death for children older than 1 year. These include accidents such as drownings, car accidents, fires, falls, and poisoning. Children are curious and naturally explore their environment, which can put them at risk for accidents. It is important for parents and caregivers to create safe environments for children, supervise them closely, and take appropriate safety precautions to prevent these injuries. By being mindful of potential hazards and actively working to prevent accidents, we can help reduce the incidence of unintentional injuries and protect children's well-being.