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The nurse is caring for a client admitted to the hospital with lower extremity edema and shortness of breath. Which electrocardiogram finding indicates the client is at risk for an alteration in perfusion?
- A. P wave smooth and round
- B. Absent U wave
- C. PR interval 0.30 seconds
- D. ST segment isoelectric
Correct Answer: D
Rationale: An isoelectric ST segment on an electrocardiogram can indicate myocardial ischemia or injury, which can lead to a decrease in perfusion to the heart muscle. This finding suggests an increased risk of inadequate blood flow to the heart, potentially resulting in further complications such as a myocardial infarction or altered perfusion to other organs. In a client with lower extremity edema and shortness of breath, identifying this ECG finding is crucial for early intervention and monitoring to prevent further deterioration in perfusion status.
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The nurse has a 7-year-old client recovering from partial-thickness burns to the arms and hands. This client has shown sensitivity to loud noises and bright lights, and at times if she is overstimulated she won't speak to or look at anyone but her parents until she calms down. The nurse considers the best teaching environment for this client to be the
- A. client's room.
- B. pediatric ward waiting area.
- C. hospital cafeteria.
- D. pediatric ward play area.
Correct Answer: A
Rationale: For a 7-year-old client recovering from partial-thickness burns with sensitivity to loud noises and bright lights, along with a tendency to become overstimulated, the best teaching environment would be the client's room. This setting provides a familiar and comforting space where the client feels secure and less exposed to external stimuli that may trigger discomfort or anxiety. Being in her own room allows the client to focus better, feel more at ease, and have better communication with the nurse without distractions from bright lights, loud noises, or other people around. This controlled and peaceful environment contributes to a more effective teaching and learning experience for the client, promoting better understanding and retention of information.
A 14-year-old child was recently diagnosed with hypertrophic cardiomyopathy. During a follow-up appointment, the mother asks the nurse, "How will this affect my child's ability to play football in the fall?" How should the nurse respond?
- A. "This shouldn't affect his ability to play football."
- B. "Children with cardiomyopathy should not play football."
- C. "He could participate in flag football but not tackle football."
- D. "This may actually make him a better, stronger football player."
Correct Answer: B
Rationale: Children diagnosed with hypertrophic cardiomyopathy should not participate in competitive sports such as football due to the potential risk of sudden cardiac events. Physical activity and sports with lower intensity may be allowed, but organized competitive sports with high intensity (such as football) are generally contraindicated. It is important for the health care team to prioritize the child's safety and well-being over sports participation in cases of cardiomyopathy. The nurse should communicate this information to the mother to help her understand the importance of limiting the child's physical activities to reduce the risk of complications related to hypertrophic cardiomyopathy.
A nurse is caring for a client who was involved in a motor vehicle accident and has lost approximately 1,550 mL of blood. The nurse should recognize that the client's shock will be classified as:
- A. Class I
- B. Class II
- C. Class III
- D. Class IV
Correct Answer: C
Rationale: Class III hemorrhagic shock typically involves the loss of 1,500-2,000 mL of blood, which aligns closely with the approximately 1,550 mL of blood lost by the client in this scenario. Class III shock is considered severe and can lead to significant physiological consequences, including decreased blood pressure, increased heart rate, altered mental status, and potential organ dysfunction. Therefore, based on the amount of blood loss and severity of symptoms, the client's shock would be classified as Class III.
During an assessment, the nurse decides to assess a patient’s calcium level. Which action will the nurse take to identify a low calcium level?
- A. Palpate turgor of skin
- B. Observe the color of the skin
- C. Conduct a Trousseau’s sign test
- D. Save urine to measure 17-ketosteroids
Correct Answer: C
Rationale: The Trousseau’s sign test is used to identify low calcium levels in a patient. This test involves inflating a blood pressure cuff on the patient's arm above systolic pressure for a few minutes, which can trigger a carpal spasm (wrist and hand flexion) in patients with low calcium levels (hypocalcemia). This is due to increased neuromuscular irritability caused by low calcium levels. Therefore, conducting a Trousseau’s sign test is the appropriate action to identify a low calcium level in a patient. Palpating turgor of skin, observing the color of the skin, and saving urine to measure 17-ketosteroids are not relevant actions for assessing calcium levels.
After being diagnosed with polycystic kidney disease, an adult patient asks if current children are at risk for developing the disorder. How should the nurse respond?
- A. The adult form of this disorder is rare and should not affect grown children
- B. The children should undergo genetic testing and screening for evidence of the disease
- C. Because the condition was just diagnosed, there is no risk of passing the condition on to any children
- D. The children would have developed symptoms of the disorder in utero or shortly after birth if they had inherited the defective gene
Correct Answer: B
Rationale: Polycystic kidney disease (PKD) is a genetic disorder that can be inherited by children if one or both parents have the gene mutation responsible for the condition. In cases where a parent has been diagnosed with PKD, their children are at risk of inheriting the faulty gene. As such, it is recommended for the children to undergo genetic testing and screening to identify any evidence of the disease early on. By identifying the gene mutation in the children, appropriate monitoring and management can be initiated, potentially leading to better outcomes and quality of life for the affected individuals. Therefore, genetic testing and screening are crucial in cases where there is a known genetic component to a disorder like PKD.