Nokea
The nurse is conducting a staff in-service on childhood-acquired heart diseases. Which is a major clinical manifestation of rheumatic fever?
- A. Polyarthritis
- B. Osler nodes
- C. Janeway spots
- D. Splinter hemorrhages of distal third of nails
Correct Answer: A
Rationale: Rheumatic fever is a systemic inflammatory condition that can develop as a complication of untreated or inadequately treated streptococcal infections, such as strep throat. One of the major clinical manifestations of rheumatic fever is polyarthritis, which is characterized by inflammation and pain in multiple joints. It typically involves large joints like the knees, ankles, elbows, and wrists. Polyarthritis in rheumatic fever is migratory in nature, meaning the joint pain shifts from one joint to another over a period of time. Other common clinical manifestations of rheumatic fever include carditis (inflammation of the heart), chorea (involuntary movements), subcutaneous nodules, and erythema marginatum (rash).
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Neuroblastoma can be associated with paraneoplastic syndromes. All the following features are paraneoplastic EXCEPT
- A. uncontrollable jerking movements
- B. cerebellar ataxia and increased body coordination
- C. unilateral ptosis, myosis, and anhidrosis
- D. profound secretory diarrhea
Correct Answer: B
Rationale: Increased body coordination is not a typical feature of neuroblastoma-associated paraneoplastic syndromes.
Which action by the nurse is appropriate?
- A. Observe the patient for abnormal bleeding.
- B. Notify the physician and expect an order to increase the warfarin dose.
- C. Advise the patient to double today's dose of warfarin.
- D. Administer Vit. K per protocol.
Correct Answer: A
Rationale: The appropriate action by the nurse is to observe the patient for abnormal bleeding. Warfarin is an anticoagulant medication, and one of its serious side effects is excessive bleeding. It is important for the nurse to monitor the patient closely for signs of abnormal bleeding, such as easy bruising, blood in urine or stool, or prolonged bleeding from cuts or wounds. This observation allows for early detection and intervention if any abnormal bleeding occurs. Notifications to the healthcare provider should also be made if abnormal bleeding is suspected. It is crucial not to make any changes to the warfarin dose or administer Vitamin K without a physician's order, as these actions can have serious consequences.
A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion?
- A. Potassium infusion
- B. NPH insulin infusion
- C. 5% dextrose infusion
- D. Normal saline infusion
Correct Answer: D
Rationale: Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes characterized by hyperglycemia, ketosis, and metabolic acidosis. The initial treatment for DKA requires correcting dehydration and electrolyte imbalances. Normal saline infusion is the preferred choice for initial fluid resuscitation in patients with DKA to address dehydration and restore intravascular volume. It helps improve organ perfusion and correct electrolyte imbalances such as hyponatremia and dehydration commonly seen in DKA patients. Administering normal saline helps replace lost fluids and improve circulation, which is crucial in the management of DKA. Potassium infusion may be needed later to replete potassium levels once the patient's kidney function has been assessed. NPH insulin infusion is not the initial treatment for DKA, although insulin therapy is an essential component of DKA management. 5% dextrose infusion is contraindicated in the initial treatment
Total parenteral nutrition (TPN) is ordered for an adult client. Which nutrient is not likely to be in the solution?
- A. dextrose
- B. electrolytes
- C. trace minerals
- D. amino acids
Correct Answer: C
Rationale: Total parenteral nutrition (TPN) is a method of providing nutrition intravenously to individuals who are unable to obtain adequate nutrition through oral or enteral routes. The components of a TPN solution typically include dextrose (a source of carbohydrates for energy), amino acids (building blocks of proteins), electrolytes (such as sodium, potassium, and magnesium to maintain proper balance), vitamins, and trace elements (such as zinc and selenium). Trace minerals are essential for various metabolic functions in the body, and their inclusion in TPN solutions is crucial to prevent deficiencies. Therefore, trace minerals are likely to be present in TPN solutions, making them an essential component, unlike the other options provided in the question.
Which of the ff. nursing interventions would have the highest priority in the plan of care for the postoperative eye patient?
- A. Do not leave the patient unattended at any time.
- B. Teach the patient not to bend over.
- C. Report sudden onset of acute pain.
- D. Apply sandbags to either side of the head.
Correct Answer: C
Rationale: In the postoperative period for an eye patient, sudden onset of acute pain can be indicative of a complication or an issue that needs immediate attention. Promptly reporting and addressing the pain is essential to prevent any further complications, such as infection, corneal abrasion, or increased intraocular pressure. This intervention takes priority over the other options listed as it involves the patient's immediate safety and well-being. It is crucial to follow postoperative protocols and report any unexpected or severe symptoms to ensure appropriate treatment and prevent any potential harm to the patient's eyesight.