Nokea
The nurse is preparing to care for a newborn receiving phototherapy. Which interventions are appropriate? (Select all that apply.)
- A. Avoid stimulation.
- B. Decrease fluid intake.
- C. Expose all the newborn's skin.
- D. Monitor skin temperature closely.
Correct Answer: A
Rationale: Avoid stimulation: Newborns receiving phototherapy are often jaundiced, and reducing stimulation helps to minimize stress and agitation, promoting better outcomes.
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For a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone (Deltasone). When caring for this client, the nurse should monitor for which adverse drug reactions?
- A. Increased weight, hypertension, and insomnia
- B. Vaginal bleeding, jaundice, and inflammation
- C. Stupor, breast lumps, and pain
- D. Dyspnea, numbness, and headache
Correct Answer: A
Rationale: Corticosteroids, like prednisone, are commonly associated with several adverse drug reactions. Increased weight is often observed due to fluid retention and increased appetite caused by corticosteroids. Hypertension can result from the sodium and water retention triggered by these medications. Insomnia is a common side effect of corticosteroids due to their stimulant effect on the central nervous system. It is important for the nurse to monitor the client for these adverse reactions and report any concerning symptoms to the healthcare provider for appropriate management.
The nurse is caring for a preterm newborn who requires mechanical ventilation for the treatment of respiratory distress syndrome. What is the preterm newborn at increased risk of due to the mechanical ventilation?
- A. Alveolar rupture
- B. Meconium aspiration
- C. Transient tachypnea
- D. Retractions and nasal flaring
Correct Answer: A
Rationale: Preterm newborns who require mechanical ventilation are at increased risk of developing alveolar rupture. The pressure from mechanical ventilation can lead to overdistension of the alveoli, causing damage to their delicate structure. This can result in the rupture of the alveolar walls, leading to a condition known as pulmonary interstitial emphysema. Alveolar rupture can contribute to the development of other complications such as pneumothorax and air leaks, which can further compromise the newborn's respiratory status. Therefore, close monitoring and adjustment of ventilation parameters are crucial in the care of preterm newborns on mechanical ventilation to minimize the risk of alveolar rupture and its associated complications.
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.
Clinical manifestations of failure to thrive caused by behavioral problems resulting in inadequate intake of calories include:
- A. avoidance of eye contact.
- B. an associated malabsorption defect.
- C. weight that falls below the 15th percentile.
- D. normal achievement of developmental landmarks.
Correct Answer: C
Rationale: Clinical manifestations of failure to thrive caused by behavioral problems resulting in inadequate intake of calories may include weight that falls below the 15th percentile on growth charts. Weight falling below the 15th percentile may indicate poor nutrition intake leading to inadequate growth and development. Other signs such as avoidance of eye contact, an associated malabsorption defect, and normal achievement of developmental landmarks may not be specific indicators of failure to thrive due to behavioral problems with inadequate calorie intake.
A 13-year-old is worried because his breasts are growing and are tender. What should the nurse tell him?
- A. We will draw blood to determine the cause.
- B. It is a slight hormonal imbalance that can be corrected with medication.
- C. It is a normal condition of puberty (gynecomastia) that usually resolves within a year or two.
- D. It is a rare finding in boys during puberty.
Correct Answer: C
Rationale: Gynecomastia and breast tenderness occur in about one-third of boys during mid-puberty and usually resolve within 2 years.