Nokea
The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?
- A. Refer for immediate medical evaluation.
- B. Continue assessment to determine cause of neck pain.
- C. Ask parent when neck was injured.
- D. Record "head lag" on assessment record, and continue assessment of child.
Correct Answer: A
Rationale: Referring the child for immediate medical evaluation is the most appropriate action in this scenario. The symptoms described, including hyperextension of the head (opisthotonos) with pain on flexion, are concerning for meningitis, a serious infection that can rapidly progress and lead to serious complications if not treated promptly. Seeking immediate medical intervention is crucial to assess and manage the child's condition effectively. Continuing with the assessment or asking about a neck injury is not recommended as the priority is to address the potential medical emergency. Recording the "head lag" without taking immediate action could delay necessary medical treatment.
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Nurse Raymond is handling a group of student nurses and he is teaching them about fluids and electrolytes. He is correct when he says that a substance moves from an area of higher concentration, this is:
- A. osmosis
- B. filtration
- C. diffusion
- D. active transport
Correct Answer: C
Rationale: Diffusion is the movement of molecules from an area of higher concentration to an area of lower concentration. In the context of fluids and electrolytes, this process plays a crucial role in maintaining the balance of these substances in the body. Nurse Raymond is correct in stating that diffusion is the mechanism by which substances move down their concentration gradient. Osmosis involves the movement of water across a semipermeable membrane, filtration is the process of separating substances based on size through a filtering mechanism, and active transport requires energy to move substances against their concentration gradient.
A client receiving ferrous sulfate (Fer-Iron) therapy to treat an iron deficiency reports taking an antacid frequently to relieve heart burn. Which nursing instruction should the nurse provide?
- A. "Take ferrous sulfate and the antacid together."
- B. "Take ferrous sulfate and the antacid at least 2 hours apart."
- C. "Avoid taking an antacid altogether."
- D. "Take ferrous sulfate and the antacid at least 1 hour apart."
Correct Answer: B
Rationale: Antacids can interfere with the absorption of iron from ferrous sulfate. Therefore, it is important to take these medications at least 2 hours apart to ensure proper absorption of the iron supplement. Taking them together can reduce the effectiveness of the ferrous sulfate therapy in treating the iron deficiency. It is not necessary to avoid taking an antacid altogether, but timing is crucial to optimize the benefits of both medications.
The LEAST important advice for a 2-month-old baby with excessive crying is
- A. master the situation in relaxed manner
- B. adhere to precry cues
- C. change milk formula
- D. avoid sensory overstimulation
Correct Answer: C
Rationale: Changing formula may not address refusal due to developmental factors.
A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100mcg IM daily. Which substance influences Vitamin B12 absorption?
- A. Intrinsic factor
- B. Histamine
- C. Hydrochloric acid
- D. Liver enzyme
Correct Answer: A
Rationale: Intrinsic factor is a glycoprotein produced by the parietal cells of the stomach. It is essential for the absorption of vitamin B12 in the intestine. Vitamin B12 binds to intrinsic factor in the stomach, forming a complex that is absorbed in the ileum of the small intestine. Without intrinsic factor, vitamin B12 absorption is significantly impaired, leading to conditions like pernicious anemia, which is a type of megaloblastic anemia caused by vitamin B12 deficiency. By administering cyanocobalamin (Betalin-12) intramuscularly, the need for intrinsic factor in the absorption process is bypassed, which is necessary in cases where intrinsic factor production or function is disrupted.
When a client is receiving blood which of the ff nursing actions is essential to determine if chilling is the result of an emerging complication or of infusing cold blood?
- A. Monitoring the client's temperature before, during, and after transfusion
- B. Documenting the client's temp after the transfusion
- C. Documenting the temp of the blood before the transfusion
- D. Comparing the client's temp with the temp of the blood
Correct Answer: A
Rationale: Monitoring the client's temperature before, during, and after transfusion is essential to determine if chilling is the result of an emerging complication or of infusing cold blood. By consistently monitoring the client's temperature at different points in the transfusion process, healthcare providers can identify any significant changes that may indicate a complication. This allows for timely intervention and appropriate management of any issues related to the blood transfusion. Comparing the client's temperature with the temperature of the blood is important but alone it may not provide a comprehensive assessment of the client's condition during the transfusion process. So, the best course of action is to monitor the client's temperature at various time points to ensure accurate assessment and early detection of any complications.