Nokea
The nurse is caring for a child with a diagnosis of Kawasaki disease. The child’s parent asks the nurse, “How does Kawasaki disease affect my child’s heart and blood vessels?†On what understanding is the nurse’s response based?
- A. Inflammation weakens blood vessels, leading to aneurysm.
- B. Increased lipid levels lead to the development of atherosclerosis.
- C. Untreated disease causes mitral valve stenosis.
- D. Altered blood flow increases cardiac workload with resulting heart failure.
Correct Answer: A
Rationale: Inflammation of vessels weakens the walls of the vessels and often results in aneurysm.
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A male client who reports feeling chronically fatigued has a hemoglobin of 11.0 grams/dl (110mmol/L), hematocrit of 34%, and microcytic and hypochromic red blood cells (RBCs). Based on these findings, which dinner selection should the nurse suggest to the client?
- A. Cheese pasta and a lettuce and tomato salad
- B. Beef steak with steamed broccoli and orange slices
- C. Broiled white fish with a baked sweet potato
- D. Grilled shrimp and season rice with asparagus salad
Correct Answer: B
Rationale: The client's lab results indicate iron deficiency anemia. Beef steak is rich in iron, and vitamin C from orange slices enhances iron absorption, making this the best choice to address the anemia.
Which is not useful to test brainstem death in suspected cervical spine injury?
- A. Pupillary light reflex
- B. Doll's-eyes reflex
- C. Corneal reflex
- D. Oculo-vestibular reflex
Correct Answer: B
Rationale: Doll's-eyes reflex is not used in suspected cervical spine injury due to the risk of further injury.
During preoperative teaching for a male client scheduled for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understands the need to perform coughing and deep breathing exercises after surgery. How should the nurse respond?
- A. Ask for a demonstration of these exercises
- B. Explain that coughing should be avoided
- C. Review the client’s previous surgical history
- D. Document the client's understanding of teaching
Correct Answer: A
Rationale: Asking for a demonstration ensures that the client understands the proper technique for coughing and deep breathing exercises.
Common diseases presenting as a rash in infancy are:
- A. Measles
- B. Parvovirus B 19 infection
- C. Leukaemia
- D. Lymphoma
Correct Answer: A
Rationale: Measles
The parents of a 3-month-old ask why their baby will not have an operation to correct a ventricular septal defect (VSD). The nurse's best response is:
- A. It is always helpful to get a second opinion about any serious condition like this.
- B. Your baby's defect is small and will likely close on its own by 1 year of age.
- C. It is common for physicians to wait until an infant develops respiratory distress before they do the surgery.
- D. With a small defect like this, they wait until the child is 10 years old to do the surgery.
Correct Answer: B
Rationale: Most small VSDs close spontaneously within the first year of life.