Nokea
The nurse is caring for a school aged child in sickle cell crisis. Which interventions are appropriate for this patient? (Select all that apply)
- A. Application of a heating pad to the painful areas
- B. Start a Morphine PCA to provide pain relief for this patient
- C. Encourage patient to ambulate often to prevent pneumonia
- D. Hydrate patient with one-and-a-half-time maintenance fluid
Correct Answer: A,B,D
Rationale: Correct Answer: A, B, D
Rationale:
A: Application of a heating pad to the painful areas helps to relieve vaso-occlusive pain in sickle cell crisis by promoting vasodilation and increasing blood flow.
B: Starting a Morphine PCA is appropriate for pain management in sickle cell crisis as it provides controlled analgesia for the patient.
D: Hydrating the patient with one-and-a-half-time maintenance fluid helps prevent dehydration and maintain adequate blood flow, reducing the risk of vaso-occlusive episodes.
Incorrect Choices:
C: Encouraging the patient to ambulate often may not be suitable during a sickle cell crisis as it can increase the risk of pain and further complications.
E, F, G: No additional choices given, but typically options not directly related to pain management, hydration, or symptom relief would be incorrect in this scenario.
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Which is the correct positioning of a child experiencing epistaxis:
- A. The child should be placed in a prone position
- B. The child should be placed in a supine position
- C. The child should be sitting with their head tilted back
- D. The child should sit up and lean forward
Correct Answer: D
Rationale: The correct positioning for a child experiencing epistaxis (nosebleed) is option D: the child should sit up and lean forward. This position helps prevent blood from flowing down the throat, reducing the risk of choking or aspiration. Sitting up also helps to reduce blood pressure in the vessels of the nose, aiding in the clotting process. Placing the child in a prone position (option A) can lead to blood flowing down the throat, causing potential airway obstruction. Placing the child in a supine position (option B) can also lead to blood going down the throat and may increase the risk of aspiration. Sitting with the head tilted back (option C) is not recommended as it can lead to blood running down the back of the throat and potentially into the airway. Therefore, option D is the correct choice for managing epistaxis in a child.
The expected finding of Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) include:
- A. Low urine output & increased levels of antidiuretic hormone
- B. Low urine output & decreased levels of antidiuretic hormone
- C. Increased urine output & decreased levels of antidiuretic hormone
- D. Increased urine output & increased levels of antidiuretic hormone
Correct Answer: A
Rationale: The correct answer is A: Low urine output & increased levels of antidiuretic hormone. In SIADH, there is an excessive release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia. This results in low urine output as the body retains water. Increased levels of ADH cause the kidneys to reabsorb more water, further contributing to low urine output. The other choices are incorrect because in SIADH, urine output is typically low, and ADH levels are elevated due to the dysregulation of the feedback mechanism that controls ADH release. Increased urine output and decreased levels of ADH (choice C) would be more indicative of diabetes insipidus, a condition characterized by decreased ADH production or kidney insensitivity to ADH.
A sign specific to red blood cell destruction (hemolytic) anemia is:
- A. Jaundice
- B. Pica
- C. Anorexia
- D. Tachycardia
Correct Answer: A
Rationale: Jaundice is the correct answer for red blood cell destruction anemia because it results from the breakdown of red blood cells, causing an increase in bilirubin levels. Jaundice presents as yellowing of the skin and eyes. Pica (eating non-food items), anorexia (loss of appetite), and tachycardia (rapid heart rate) are not specific signs of hemolytic anemia. Jaundice is a key indicator due to the excess bilirubin released from the destruction of red blood cells.
A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?
- A. Pale and a 24-hr fluid deficit of 30 mL
- B. Sunken fontanels and dry mucous membranes
- C. Decreased appetite and irritability
- D. Temperature 38° C (100.4° F) and pulse rate 124/min
Correct Answer: B
Rationale: The correct answer is B: Sunken fontanels and dry mucous membranes. These findings indicate severe dehydration in the infant with gastroenteritis. Sunken fontanels suggest significant fluid loss, while dry mucous membranes also indicate dehydration. Dehydration in infants can lead to serious complications, so it is crucial for the nurse to report these findings to the provider promptly.
The other choices are not as concerning as choice B. Choice A indicates a fluid deficit but does not suggest severe dehydration. Choice C could be expected in a sick infant and does not require immediate provider notification. Choice D shows signs of fever and tachycardia, which are common in gastroenteritis and may not be as urgent as severe dehydration.
Which is the most accurate genetic explanation for a family with hemophilia?
- A. It is an X-linked recessive disorder
- B. It is an autosomal recessive disorder
- C. It is equally distributed among males and females
- D. It is a Y-linked dominant disorder
Correct Answer: A
Rationale: The correct answer is A: It is an X-linked recessive disorder. Hemophilia is caused by a mutation in genes located on the X chromosome. Males inherit the disorder from their mothers, as they only inherit one X chromosome. Females can be carriers if they inherit one mutated X chromosome. Autosomal recessive disorders (choice B) require both parents to pass on the mutated gene. Hemophilia is not equally distributed among males and females (choice C) because males are more likely to exhibit symptoms. Y-linked disorders (choice D) are inherited only by males and are passed from father to son.