Nokea
The nurse is conducting discharge teaching about signs and symptoms of heart failure to parents of an infant with a repaired tetralogy of Fallot. Which signs and symptoms should the nurse include? (Select all that apply.)
- A. Warm flushed extremities
- B. Weight loss
- C. Decreased urinary output
- D. Sweating (inappropriate)
Correct Answer: C
Rationale: C. Decreased urinary output: This can be a sign of fluid retention, which is a common symptom of heart failure. Infants with heart failure may have decreased urine output as the body tries to retain fluid to help compensate for the heart's decreased ability to pump effectively.
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The parent of a 2-week-old infant, exclusively breastfed, asks the nurse if fluoride supplements are needed. What is the nurse's best response?
- A. "She needs to begin taking them now."
- B. "They are not needed if you drink fluoridated water."
- C. "She may need to begin taking them at age 4 months."
- D. "She can have infant cereal mixed with fluoridated water instead of supplements."
Correct Answer: B
Rationale: The nurse's best response to the parent of a 2-week-old infant, exclusively breastfed, regarding the need for fluoride supplements is that they are not needed if the infant is already drinking fluoridated water. Fluoride supplements are typically recommended for infants who are not receiving enough fluoride through their water source. Breast milk itself does not contain a significant amount of fluoride, but if the family's water supply is fluoridated, the infant will likely receive an adequate amount of fluoride without the need for supplements. It is important for the parent to verify the fluoride content of their water supply with their local water utility to ensure the infant is receiving the appropriate amount of fluoride for dental health.
Mr. Garcia, a 41-year old chronic alcohol drinker is admitted to the hospital after vomiting bright red blood. He was diagnosed to have a bleeding gastric ulcer and suddenly develops sudden sharp pain in the midepigastric region with a rigid boardlike abdomen. This likely indicates:
- A. development of intestinal
- B. inflammation of the esophagus
- C. perforation of the ulcer
- D. development of additional ulcers
Correct Answer: C
Rationale: The sudden sharp pain in the midepigastric region with a rigid boardlike abdomen in a patient with a bleeding gastric ulcer, especially in the setting of chronic alcohol use, is indicative of a perforation of the ulcer. Perforation occurs when the ulcer penetrates through the wall of the stomach or duodenum, leading to the leakage of gastric contents into the peritoneal cavity. This results in peritonitis, causing severe abdominal pain and rigidity. Perforation of the ulcer is a surgical emergency requiring immediate intervention to repair the perforation, control the infection, and prevent further complications like sepsis. It is a life-threatening condition that necessitates prompt diagnosis and management.
Nurse Analiza is administering a medication via the intraosseous route to a child. Intraosseous drug administration is typically used when a child is:
- A. Under age 3
- B. Over age 3
- C. Critically ill and under age 3
- D. Critically ill and over age 3
Correct Answer: C
Rationale: Intraosseous drug administration is typically reserved for pediatric patients who are critically ill and under the age of 3. This route is chosen when intravenous access cannot be readily established or when the patient is in urgent need of medication administration. Young children have easily accessible bone marrow spaces, making intraosseous administration a quick and effective means of delivering medications in emergency situations. Older children tend to have more developed vasculature, making it easier to establish intravenous access in those cases.
The first thing to do for a nurse when an accident occurs is to find out if patient is conscious so that she could:
- A. Reassure the patient
- B. Call relatives
- C. Bring patient immediately to the hospital
- D. Call a doctor
Correct Answer: A
Rationale: The first thing a nurse should do when an accident occurs is to assess the patient's level of consciousness. This is important to determine the patient's immediate medical needs and to ensure the patient's safety. By checking if the patient is conscious, the nurse can assess the patient's alertness and responsiveness, which will help in providing appropriate care. Reassuring the patient is crucial to help calm them down and provide comfort in a stressful situation. Once the nurse has established the patient's level of consciousness, they can then proceed with necessary medical interventions such as contacting a doctor or bringing the patient to the hospital if needed.
Which of the following may be the first abnormal sign detected in a client with cardiomyopathy?
- A. Ascites c.Chest pain
- B. Heart murmur
- C. Dyspnea
Correct Answer: C
Rationale: Dyspnea, or difficulty breathing, may be the first abnormal sign detected in a client with cardiomyopathy. Cardiomyopathy is a disease of the heart muscle, which can lead to impaired heart function. As the heart's ability to pump blood effectively is compromised, the body may not receive an adequate supply of oxygen-rich blood. This can result in symptoms such as dyspnea, especially during physical exertion or when lying down. Ascites (fluid accumulation in the abdomen), chest pain, and heart murmur may also be seen in clients with cardiomyopathy but are not typically the first signs to present. Dyspnea is often a key indicator that should prompt further evaluation and monitoring for cardiac issues.