Nokea
The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
- A. "Client will lose 2lb per week on a calorie-restricted diet."
- B. "Client will exhibit no signs or symptoms of aspiration."
- C. "Client will exhibit bowel and bladder continence."
- D. "Client will exhibit alertness and orientation to person, place, and time."
Correct Answer: B
Rationale: Polymyositis is a condition that involves inflammation of the muscles, including the muscles involved in swallowing (dysphagia) and breathing. This can lead to a higher risk of aspiration, where food or fluids go into the airway instead of the esophagus. Therefore, monitoring for signs and symptoms of aspiration and ensuring the client exhibits no signs of aspiration are crucial in the care of a client with polymyositis. The other options are not directly related to the potential problems associated with polymyositis and are more general aspects of nursing care.
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A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?
- A. Potential hepatic dysfunction indicated by decreased blood urea nitrogen (BUN) and creatinine levels
- B. Low levels of urine constituents normally excreted in the urine
- C. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels
- D. Electrolyte imbalance that could affect the blood's ability to coagulate properly
Correct Answer: C
Rationale: A complete blood count (CBC) is a common blood test that provides important information about the types and numbers of cells in the blood, such as red blood cells, white blood cells, and platelets. The primary purpose of performing a CBC before surgery is to identify any abnormalities in the blood that could affect the patient's ability to undergo the surgical procedure safely. Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels indicated by a CBC may suggest anemia, which could impact the patient's ability to tolerate surgery and anesthesia. Anemia can result in decreased oxygen delivery to tissues and organs, leading to potential complications during surgery. Therefore, identifying low HCT and Hb levels through a CBC allows healthcare providers to take appropriate measures to address and manage the condition before proceeding with surgery.
Which is an important nursing consideration when caring for a child with herpetic gingivostomatitis (HGS)?
- A. Apply topical anesthetics before eating.
- B. Drink from a cup, not a straw.
- C. Wait to brush teeth until lesions are sufficiently healed.
- D. Explain to parents how this is sexually transmitted.
Correct Answer: C
Rationale: An important nursing consideration when caring for a child with herpetic gingivostomatitis (HGS) is to wait to brush teeth until lesions are sufficiently healed. This is because brushing teeth while the lesions are present can be painful and potentially disruptive to the healing process. It is important to ensure that the child is comfortable and that the healing of the lesions is not impeded by brushing too early. This consideration helps promote optimal healing and comfort for the child with this condition.
Which is the leading cause of death from unintentional injuries for females ranging in age from 1 to 14?
- A. Mechanical suffocation
- B. Drowning
- C. Motor vehicle–related fatalities
- D. Fire- and burn-related fatalities
Correct Answer: C
Rationale: According to the Centers for Disease Control and Prevention (CDC), motor vehicle–related fatalities are the leading cause of death from unintentional injuries for females aged 1 to 14. This is a significant risk factor for young girls in this age group, highlighting the importance of road safety measures and injury prevention strategies. Factors such as proper car seat usage, seat belt use, and safe driving practices are crucial in reducing the number of motor vehicle-related fatalities among young females aged 1 to 14.
Although melanoma is relatively rare in children, some risk factors may increase its incidence. All the following are risk factors for development of melanoma EXCEPT
- A. positive family history of melanoma
- B. dark-skinned child
- C. hairy nevus
- D. dysplastic nevus
Correct Answer: B
Rationale: Dark-skinned individuals have a lower risk of melanoma.
A hospitalized child with minimal change nephrotic syndrome is receiving high doses of prednisone. Which is an appropriate nursing goal related to this?
- A. Prevent infection
- B. Stimulate appetite
- C. Detect evidence of edema
- D. Ensure compliance with prophylactic antibiotic therapy
Correct Answer: C
Rationale: Nephrotic syndrome is characterized by the presence of edema due to loss of protein in the urine. One of the nursing goals in managing a child with minimal change nephrotic syndrome receiving high doses of prednisone is to monitor for the development or worsening of edema. Detecting evidence of edema is important as it can help in assessing the effectiveness of treatment, such as monitoring the response to prednisone therapy and adjusting the treatment plan accordingly. Monitoring for edema can also help in preventing complications associated with fluid overload, such as hypertension and respiratory distress. Therefore, detecting evidence of edema is an appropriate nursing goal in this scenario.