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The nurse is caring for an adolescent who has just started dialysis. The child seems always angry, hostile, or depressed. To what are these behaviors most likely related?
- A. Neurologic manifestations that occur with dialysis
- B. Physiologic manifestations of renal disease
- C. Adolescents having few coping mechanisms
- D. Adolescents often resenting the control and enforced dependence imposed by dialysis
Correct Answer: D
Rationale: Adolescents often resent the control and enforced dependence imposed by dialysis. Adolescence is a challenging time marked by striving for independence and autonomy. When adolescents have to rely on medical interventions like dialysis that impose control and dependence, it can lead to feelings of anger, hostility, and depression. This is a normal psychological response to feeling restricted and not in control of their own lives. It is important for healthcare providers to recognize these emotions and provide support and coping strategies to help the adolescent adjust to the situation.
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When assessing a client with autoimmune disorder, what signs should the nurse look for in the client?
- A. Hypotension
- B. Hives or rashes
- C. Localized inflammation
- D. Cramping and vomiting
Correct Answer: B
Rationale: When assessing a client with an autoimmune disorder, the nurse should look for signs such as hives or rashes. Autoimmune disorders can manifest with various skin manifestations, including hives or rashes, which may be indicative of an autoimmune response. These skin manifestations may occur due to the immune system mistakenly attacking the body's own tissues. Observing and monitoring these skin changes can help in assessing and managing the autoimmune disorder in the client. Additionally, localized inflammation may also be present in autoimmune disorders, but hives or rashes are more commonly associated with these conditions.
12-year-old Caroline has recurring nephrotic syndrome; which of the following areas of potential disturbances should be a prime consideration when planning ongoing nursing care?
- A. Body image
- B. Sexual maturation
- C. Muscle coordination
- D. Intellectual development
Correct Answer: A
Rationale: For 12-year-old Caroline with recurring nephrotic syndrome, body image should be a prime consideration when planning ongoing nursing care. Nephrotic syndrome can cause physical changes such as weight gain, swelling, and changes in appearance due to the disease process and treatment side effects like corticosteroids. These physical changes can impact a child's self-esteem and body image, especially during the sensitive pre-adolescent period. As a result, addressing Caroline's body image concerns through open communication, providing support, promoting self-acceptance, and involving her in decision-making regarding her care can significantly impact her emotional well-being and overall quality of life.
A 3-day-old neonate has a large, soft, painless mass involving the head and neck region that mostly transilluminate; CT scan reveals a cystic mass involving the neck and intrathoracic mediastinum. The BEST modality for treatment of this neonate is
- A. surgical resection
- B. injection sclerosing agent
- C. laser therapy
- D. systemic interferon therapy
Correct Answer: A
Rationale: Surgical resection is the definitive treatment for cystic hygroma.
A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement?
- A. Related to visual field deficits
- B. Related to impaired balance
- C. Related to difficulty swallowing
- D. Related to psychomotor seizures
Correct Answer: B
Rationale: A client with a cerebellar brain tumor is likely to experience impaired balance due to the location of the tumor affecting the cerebellum, which is responsible for coordinating movement and balance. Impaired balance increases the risk for falls and other injuries, making it a priority concern for the client. Therefore, adding "Related to impaired balance" to the nursing diagnosis statement would be the most appropriate choice to address the client's risk for injury in this situation.
The stump of the umbilical cord usually separates in how many days?
- A. 3
- B. 10 to 14
- C. 16 to 20
- D. 28
Correct Answer: B
Rationale: The stump of the umbilical cord usually separates from the baby's belly button within 10 to 14 days after birth. During this time, it is important to keep the area clean and dry to prevent infection. Once the stump falls off, a small open wound may be left behind, which should also be kept clean and dry until it completely heals. It is normal for a small amount of blood or discharge to be present during this process, but if there are signs of infection such as redness, swelling, or foul odor, it is important to contact a healthcare provider for further evaluation and treatment.