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The nurse is caring for a child after heart surgery. What should the nurse do if evidence of cardiac tamponade is found?
- A. Increase analgesia
- B. Apply warming blankets
- C. Immediately report this to physician
- D. Encourage child to cough, turn, and breathe deeply
Correct Answer: C
Rationale: If evidence of cardiac tamponade is found in a child after heart surgery, it is crucial for the nurse to immediately report this to the physician. Cardiac tamponade is a serious condition where excess fluid or blood accumulates in the pericardial sac, compressing the heart and affecting its ability to pump effectively. Prompt recognition and intervention are essential to prevent potential life-threatening outcomes. The physician would need to assess the child's condition, consider performing procedures to relieve the tamponade such as pericardiocentesis, and provide appropriate treatment to stabilize the child. Delaying reporting and action in cases of cardiac tamponade can lead to further complications and worsen the child's condition.
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A 36-year-old man is scheduled for a unilateral orchiectomy for treatment of testicular cancer. He is withdrawn and does not interact with the nurse. Which action is most appropriate?
- A. Identify the problem with a nursing diagnosis of impaired communication related to the diagnosis of cancer
- B. Set a patient outcome that the patient will verbalize his concerns about his diagnosis
- C. Ask the patient whether he is worried about future sexual functioning
- D. Say, "You seem quiet. Are you feeling concerned about your diagnosis or treatment?"
Correct Answer: D
Rationale: Option D is the most appropriate action in this scenario because it demonstrates empathy and opens the door for the patient to express his concerns. By acknowledging the patient's withdrawn behavior and directly inquiring about his feelings regarding the diagnosis or treatment, the nurse creates an opportunity for the patient to share his thoughts and concerns. This open-ended question allows the patient to express himself without any assumptions or judgments. It shows that the nurse is attentive, supportive, and willing to listen to the patient's emotional needs during this challenging time.
The clue to need a help for a child who does not respond correctly to 'Give me' or 'Sit down' or 'Come here' when spoken without gestural cues is by age of
- A. 15 months
- B. 18 months
- C. 21 months
- D. 24 months
Correct Answer: D
Rationale: By 24 months, a child should be able to follow simple commands without gestures.
An 8-year-old girl asks the nurse how the blood pressure apparatus works. What is the most appropriate nursing action?
- A. Ask her why she wants to know.
- B. Determine why she is so anxious.
- C. Explain in simple terms how it works.
- D. Tell her she will see how it works as it is used.
Correct Answer: C
Rationale: The most appropriate nursing action when an 8-year-old girl asks how the blood pressure apparatus works is to explain in simple terms how it works. Children are curious by nature and providing a simple explanation in a language they can understand helps satisfy their curiosity and also promotes their understanding. By explaining how the blood pressure apparatus works, the nurse can educate the child about a common medical device and reduce any anxiety or fear the child may have about it. This approach encourages the child to feel more comfortable and engaged in their healthcare experience.
A patient has hand-foot syndrome related to his sickle cell anemia. What findings does the nurse expect to see as the patient is assessed?
- A. Unequal growth of fingers and toes.
- B. Purplish discoloration of hands and feet.
- C. Webbing between fingers and toes.
- D. Deformities of the wrists and ankles.
Correct Answer: B
Rationale: Hand-foot syndrome, also known as dactylitis, is a common manifestation of sickle cell anemia. It is characterized by painful swelling and inflammation of the hands and feet, often resulting in a purplish discoloration due to decreased blood flow and oxygen delivery to the affected areas. This condition typically affects the soft tissues and joints of the hands and feet, leading to pain, swelling, and limited mobility. Unequal growth of fingers and toes, webbing between fingers and toes, and deformities of the wrists and ankles are not typically associated with hand-foot syndrome in sickle cell anemia.
A child is diagnosed with Wilms' tumor. During assessment, the nurse in charge expects to detect:
- A. Gross hematuria
- B. Dysuria
- C. Nausea and vomiting
- D. An abdominal mass
Correct Answer: D
Rationale: In a child with Wilms' tumor, the nurse would expect to detect an abdominal mass upon assessment. Wilms' tumor, also known as nephroblastoma, is a type of kidney cancer that commonly presents as a firm, non-tender abdominal mass. This mass may be felt upon palpation of the abdomen. Gross hematuria (A) is not a typical finding associated with Wilms' tumor. Dysuria (B) is the term used to describe painful or difficult urination and is not a characteristic symptom of Wilms' tumor. Nausea and vomiting (C) are also not commonly associated with Wilms' tumor, unless the tumor is causing obstruction or compression of nearby structures in the abdomen.