Nokea
The nurse is assisting with the admission of an 8-year-old client with suspected Reye syndrome. Which of the following information obtained during admission would be most consistent with the condition?
- A. no history of varicella vaccination
- B. recent exposure to bats
- C. previous exposure to lead-based paint
- D. recent influenza infection
Correct Answer: D
Rationale: Reye syndrome is associated with aspirin use during viral infections like influenza, making recent influenza infection most consistent.
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The nurse is reinforcing teaching for the parents of a child newly diagnosed with hemophilia. Which long-term complication is important for the nurse to discuss?
- A. Heart valve injury
- B. Intellectual disability
- C. Joint destruction
- D. Recurrent pneumonia
Correct Answer: C
Rationale: Hemophilia causes recurrent joint bleeds, leading to joint destruction (hemophilic arthropathy), a key long-term complication.
A parent calls the clinic about a 3-year-old who is sick with the flu. Which report by the parent would necessitate intervention by the nurse?
- A. Acetaminophen being given every 4 hours for fever
- B. Bismuth subsalicylate being used for nausea
- C. Ibuprofen being given every 6 hours for body aches
- D. Popsicles and gelatin desserts being used for hydration
Correct Answer: B
Rationale: Bismuth subsalicylate is contraindicated in children with viral infections due to Reye syndrome risk, requiring intervention. Other actions are appropriate.
A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse?
- A. a report of 10 pounds weight loss in the last month
- B. a comment by the client 'I just can't sit still.'
- C. the appearance of eyeballs that appear to 'pop' out of the client's eye sockets
- D. a report of the sudden onset of irritability in the past 2 weeks
Correct Answer: C
Rationale: Exophthalmos or protruding eyeballs is a distinctive characteristic of Graves' Disease. It can result in corneal abrasions with severe eye pain or damage when the eyelid is unable to blink down over the protruding eyeball. Eye drops or ointment may be needed.
The nurse is planning a staff education program about intimate partner violence. Which of the following information should the nurse include? Select all that apply.
- A. Intimate partner violence is most common in high-income families.
- B. Intimate partner violence is rare in same-sex partnerships.
- C. The abusive partner often demonstrates jealousy and possessiveness.
- D. Victims may not leave due to financial concerns or fear of harm by the abuser.
- E. Violence against a female often intensifies during pregnancy.
Correct Answer: C,D,E
Rationale: Jealousy/possessiveness, barriers to leaving (financial/fear), and increased violence during pregnancy are accurate. Violence is not limited to high-income families and occurs in same-sex partnerships.
The nurse is measuring the uterine fundal height of a client at 36 weeks gestation lying in a supine position. The client suddenly reports dizziness, and the nurse observes pallor and damp, cool skin. What should the nurse do first?
- A. Alert the supervising registered nurse
- B. Check the client's blood pressure and pulse
- C. Listen to the fetal heart rate
- D. Turn the client to a lateral position
Correct Answer: D
Rationale: Symptoms suggest supine hypotensive syndrome; turning the client to a lateral position relieves uterine pressure on the vena cava, improving blood flow.