Nokea
A nurse is caring for a child with measles.
- A. "Provide diversional activities such as video games."'
- B. "Maintain isolation for 48 hr after the rash resolves."'
- C. "Keep the child warm with adequate undergarments and bedding."'
- D. "Administer vitamin A supplements as prescribed."'
Correct Answer: D
Rationale: The correct answer is D because administering vitamin A supplements is a standard treatment for measles to reduce complications and improve recovery. Vitamin A deficiency is common in children with measles, and supplementation can help boost the immune system and reduce the severity of the illness. Providing diversional activities (choice A) may be suitable but does not directly address the medical needs of the child. Maintaining isolation (choice B) is important but typically lasts until 4 days after rash onset, not just 48 hours after rash resolution. Keeping the child warm (choice C) is a general comfort measure and may not directly impact measles treatment.
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Which is a major difference in the clinical manifestation of adolescents with anorexia nervosa compared to bulimia?
- A. Binge eating
- B. Purging
- C. Body image distortion
- D. Decreased self esteem
Correct Answer: C
Rationale: The major difference between adolescents with anorexia nervosa and those with bulimia is body image distortion. Clients with anorexia see themselves as being overweight no matter how underweight they become. Clients with bulimia see their weight realistically but have psychological problems that manifest in an eating disorder. Both disorders may involve binge eating and purging, but body image perception is a distinguishing factor.
A client delivered vaginally six hours ago. Which assessment finding can be interpreted as normal?
- A. Temperature 100.0 degrees F
- B. Blood pressure 140/90
- C. Respirations 10
- D. Pulse 90
Correct Answer: A
Rationale: The correct answer is A: Temperature 100.0 degrees F. This finding can be interpreted as normal because a slight increase in body temperature after childbirth is expected due to the physiological changes during labor. A temperature of 100.0 degrees F is within the normal range for postpartum women.
Rationale for why the other choices are incorrect:
B: Blood pressure 140/90 - This blood pressure reading is slightly elevated and may indicate hypertension, which would not be considered normal postpartum.
C: Respirations 10 - A respiratory rate of 10 is abnormally low and could indicate respiratory distress rather than normal postpartum recovery.
D: Pulse 90 - A pulse rate of 90 may be within normal limits, but it is not as indicative of normal postpartum recovery as a slightly elevated temperature would be.
The nursery nurse reviews a newborn's birth history and notes that the Apgar scores were 5 at one minute after birth, and 7 at five minutes after birth. How should the nurse interpret these scores? The infant:
- A. Needed brief oral and nasal suctioning.
- B. Required endotracheal intubation and bagging with a hand-held resuscitator.
- C. Was stillborn and required CPR.
- D. Required physical stimulation and supplemental oxygen.
Correct Answer: D
Rationale: The correct answer is D: Required physical stimulation and supplemental oxygen. The Apgar score assesses a newborn's overall condition at birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 5 at one minute indicates the infant needed assistance, such as stimulation to breathe and oxygen support. The score of 7 at five minutes shows improvement but still requires some intervention. Choices A, B, and C are incorrect because they suggest more aggressive interventions that are not indicated based on the Apgar scores provided, as the infant's condition was not critical enough to warrant those actions.
A nurse is reinforcing teaching to a group of parents about preventing accidental poisoning in preschoolers. Which of the following should the nurse include?
- A. Have syrup of ipecac available in the home.
- B. Explain to preschool children that plants can be eaten only after they are cooked.
- C. Keep labels on containers of toxic substances and never remove them.
- D. Place medications in a cabinet above the sink.
Correct Answer: C
Rationale: The correct answer is C: Keep labels on containers of toxic substances and never remove them. This is important to prevent accidental poisoning in preschoolers as it helps parents and caregivers easily identify and differentiate toxic substances from safe ones. Removing labels can lead to confusion and increase the risk of accidental ingestion. Having syrup of ipecac available (choice A) is no longer recommended as a first-aid treatment for poisoning. Teaching children to cook plants before eating them (choice B) is not a practical or safe approach. Placing medications in a cabinet above the sink (choice D) may not be effective as preschoolers can still access them if the cabinet is not securely locked.
The dosage of a pediatric medication is 120mg/kg/day to be given t.i.d. The patient weighs 12 pounds. What is the correct dose for the nurse to administer?
- A. 120 mg
- B. 480 mg
- C. 218 mg
- D. 651 mg
Correct Answer: C
Rationale: The patient weighs twelve pounds, which converts to kilograms by dividing 12 by 2.2 (1 kg = 2.2 lb.). In this example, the child's weight converts to 5.4 kg. The daily dose of 120 mg is given t.i.d: each individual dose is 40 mg/kg. Then multiply the weight in kilograms by the individual dose (40mg). The individual dose is 218 mg.