Nokea
The nurse is assessing a child admitted with a diagnosis of rheumatic fever. Which significant question should the nurse ask the child's parent during the assessment?
- A. Has your child had difficulty urinating?
- B. Has your child been exposed to anyone with chickenpox?
- C. Has any family member had a sore throat within the past few weeks?
- D. Has any family member had a gastrointestinal disorder in the past few weeks?
Correct Answer: C
Rationale: Rheumatic fever characteristically presents 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the respiratory tract. Initially the nurse determines whether any family member has had a sore throat or unexplained fever within the past few weeks. The remaining options are unrelated to the assessment findings of rheumatic fever.
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The nurse judges that the parent of a 9-month-old infant in a hip spica cast understands how to feed the child when the parent states which of the following?
- A. I can lay my child flat and feed that way.'
- B. I'll raise my child's head up and leave the hips and legs on a pillow.'
- C. I can borrow a special feeding table to use.'
- D. It will take two of us, one to hold and one to feed.'
Correct Answer: B
Rationale: Raising the infant's head while keeping the hips and legs supported minimizes the risk of aspiration and accommodates the hip spica cast's restrictions. Laying flat increases aspiration risk, and the other options are impractical or unnecessary.
When a rubella vaccine is administered to a client who delivered a healthy newborn 2 days ago, the nurse provides instructions to the client regarding the potential risks associated with this vaccination. Which statement by the client indicates an understanding of the medication?
- A. I need to stay out of the sunlight for 3 days.
- B. The injection site may itch, but I can scratch it if I need to.
- C. I need to avoid sexual intercourse for 2 to 3 days after the vaccination.
- D. I need to prevent becoming pregnant for 2 to 3 months after the vaccination.
Correct Answer: D
Rationale: Rubella vaccine is a live attenuated virus that evokes an antibody response and provides immunity for approximately 15 years. Because rubella is a live vaccine, it will act as the virus and is potentially teratogenic in the organogenesis phase of fetal development. The client needs to be informed about the potential effects this vaccine may have and the need to avoid becoming pregnant for a period of 2 to 3 months afterward. Sunlight has no effect on the person who is vaccinated. The vaccine may cause local or systemic reactions, but all are mild and short-lived. Abstinence from sexual intercourse is not necessary, unless another form of effective contraception is not being used.
The nurse is caring for a client with a closed head injury. Which finding indicates increasing intracranial pressure?
- A. Widening pulse pressure
- B. Tachycardia
- C. Hyperthermia
- D. Hypotension
Correct Answer: A
Rationale: Widening pulse pressure (e.g., increasing systolic with stable diastolic) is a sign of increasing intracranial pressure, part of Cushing's triad.
The nurse is performing Leopold’s maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown below. Which of the following maneuvers is the nurse performing?
- A. First maneuver.
- B. Second maneuver.
- C. Third maneuver.
- D. Fourth maneuver.
Correct Answer: C
Rationale: The third maneuver is used to identify the presenting part. This maneuver is used to identify the part of the fetus that lies over the inlet to the pelvis. While facing the client, the nurse places the tips of the fi rst three fi ngers on the side of the woman’s abdomen above the symphysis pubis and palpates deeply around the presenting part to identify its contour and size. The first maneuver involves using the tips of the fi ngers of both hands to palpate the uterine fundus. The second maneuver identifi es the back of the fetus, and the fourth maneuver identifies the cephalic prominence
Which of the following indicates that a 5-month-old weighing 15 lb and being treated for dehydration has a normal urine output? The urine output is:
- A. 1 to 2 mL/kg/hour.
- B. 3 to 5 mL/kg/hour.
- C. 6 to 8 mL/kg/hour.
- D. 10 to 12 mL/kg/hour.
Correct Answer: A
Rationale: Normal urine output for an infant is 1 to 2 mL/kg/hour, indicating adequate hydration. Higher outputs may suggest overhydration or other issues.