Nokea
The nurse is aware that a common physiologic adaptation of children with tetralogy of Fallot is:
- A. Clubbing of fingers
- B. Slow, irregular respirations
- C. Subcutaneous hemorrhages
- D. Decreased red blood cell count
Correct Answer: A
Rationale: Clubbing of fingers is a common physiologic adaptation seen in children with tetralogy of Fallot. Clubbing is the result of chronic hypoxia and decreased oxygen levels in the blood. In children with tetralogy of Fallot, there is a structural defect in the heart that leads to mixing of oxygenated and deoxygenated blood in the heart and decreased oxygenation of the blood circulating to the body. This chronic hypoxia can cause clubbing of the fingers, where the tips of the fingers appear enlarged and the nails are rounded. Therefore, clubbing of fingers is a key sign to monitor in children with tetralogy of Fallot.
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Which of the ff. nursing actions is most appropriate when doing perineal care on an uncircumcised male patient?
- A. Leave the foreskin retracted so air can keep the area dry
- B. Do not retract the foreskin during washing
- C. Replace the foreskin over the head of the penis after washing
- D. Use alcohol and a cotton swab to clean under the foreskin
Correct Answer: C
Rationale: When performing perineal care on an uncircumcised male patient, it is important to replace the foreskin over the head of the penis after washing. The foreskin should not be left retracted or pulled back forcibly as it can cause irritation and discomfort to the patient. Leaving the foreskin retracted can also lead to potential complications such as paraphimosis, where the foreskin becomes trapped behind the head of the penis. Proper hygiene involves gently retracting the foreskin to clean underneath it and then returning it to its natural position to protect the sensitive glans penis. Using gentle, warm water with mild soap is typically sufficient for cleaning, and alcohol should be avoided as it can cause irritation and dryness to the sensitive genital area.
A child 2 years 6 months of age has arranged a play date with a neighbor's child aged 2 years 9 months. During the play date, which behavior is most typical for children of this age?
- A. Share and trade toys while playing.
- B. Play with one another with little or no conflict.
- C. Engage in parallel play (playing alongside but not directly with one another).
- D. Play with only one or two items, ignoring most of the other toys.
Correct Answer: C
Rationale: Toddlers typically engage in parallel play rather than cooperative play.
Prenatal exposure to cigarette smoke is associated with
- A. shorter neonatal length
- B. lower birthweight
- C. changes in neonatal behavior
- D. neonatal diabetes
Correct Answer: D
Rationale: Neonatal diabetes is not commonly associated with prenatal cigarette smoke exposure.
Regarding physical growth of preschool children (3-5 years), all are true EXCEPT
- A. 7-8 kg weight increment/yr
- B. 20 primary teeth erupted by 3 years
- C. brain stops myelinization by 8 years
- D. height increment/yr average is 5-6 cm up to 18 years
Correct Answer: A
Rationale: Weight increment varies and is generally less than 7-8 kg/yr.
To prevent leakage of fluid in the thoracic cavity, how will you position the client after thoracentesis?
- A. Place flat in bed
- B. Turn on the affected side
- C. Turn on the unaffected side
- D. On bed rest SENSORY DISORDERS
Correct Answer: C
Rationale: After thoracentesis, it is important to position the client on the unaffected side to prevent leakage of fluid into the thoracic cavity. Placing the client on the unaffected side helps to promote proper drainage and reduce the risk of complications such as pneumothorax or fluid leakage. This position also allows for adequate lung expansion and facilitates proper re-expansion of the lung on the side where the fluid was removed. It is essential to follow this positioning to optimize outcomes and minimize risks associated with the procedure.