The nurse is caring for a child with cystic fibrosis. Which intervention is most important when the child is hospitalized with a respiratory infection?
- A. Administer prescribed antibiotics as soon as possible.
- B. Increase fluid intake to help thin mucus.
- C. Provide respiratory treatments and postural drainage.
- D. Encourage high-calorie, high-protein meals.
Correct Answer: C
Rationale: Respiratory treatments and postural drainage are critical to help clear mucus from the lungs in children with cystic fibrosis, especially during respiratory infections.
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Factors triggering renin stimulation:
- A. Hyponatraemia
- B. ACTH
- C. Hypovolaemia
- D. ANP
Correct Answer: C
Rationale: Hypovolaemia
The nurse assesses a client being treated for Herpes Zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment? (Select all that apply)
- A. Skin integrity
- B. Functional ability
- C. Heart sounds
- D. Pain scale
Correct Answer: A
Rationale: These assessments help determine the effectiveness of treatment in managing pain, skin lesions, and the client's ability to perform daily activities.
Concerning Ebstein-Barr virus (infectious mononucleosis):
- A. Presence of petechiae between the hard and soft palate supports the diagnosis
- B. Typically a rash following administration of penicillin V occurs
- C. Guillain-Barre syndrome is a recognised sequel
- D. Hepatitis is common
Correct Answer: A
Rationale: Petechiae between the hard and soft palate are a classic sign of infectious mononucleosis. A rash following penicillin V is also common, and Guillain-Barre syndrome is a rare complication.
How would the nurse caring for an infant with congestive heart failure (CHF) modify feeding techniques to adapt for the child's weakness and fatigue? (Select all that apply.)
- A. Feeding more frequently with smaller feedings
- B. Using a soft nipple with enlarged holes
- C. Holding and cuddling the child during feeding
- D. Substituting glucose water for formula
Correct Answer: A
Rationale: Infants with CHF fatigue easily. Feeding can be given more frequently in smaller amounts through a soft, large-holed nipple. Formulas with a denser caloric content can be offered. The child may be encouraged to nurse if he or she is held.
A child has an elevated antistreptolysin O (ASO) titer. Which combination of symptoms, in conjunction with this finding, would confirm a diagnosis of rheumatic fever?
- A. Subcutaneous nodules and fever
- B. Painful, tender joints, and carditis
- C. Erythema marginatum and arthralgia
- D. Chorea and elevated sedimentation rate
Correct Answer: B
Rationale: The presence of two major Jones criteria would indicate a high probability of rheumatic fever.