Nokea
The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother either staying in the room or leaving. How should this action be interpreted?
- A. Appropriate because of child's age
- B. Appropriate because mother would be uncomfortable making decisions for child
- C. Inappropriate because of child's age
- D. Inappropriate because child is same sex as mother
Correct Answer: A
Rationale: It is appropriate for the nurse to offer the 10-year-old girl the option of having her mother stay in the room during the physical assessment because of the child's age. At this age, children may start to seek more independence and privacy, and allowing the child to make the decision can help promote a sense of autonomy and respect for her feelings. It is important to consider the child's preferences and comfort during medical procedures, which can help build trust and improve the overall experience for the child.
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A patient has been prescribed bumetanide (Bumex) every morning for control of hypertension. Which of the ff. statements indicates correct knowledge of the treatment regimen?
- A. "I can travel to Florida and sunbathe all day."
- B. "Now I can eat whatever I want, whenever I want."
- C. "I'll take my medication in the morning, every morning."
- D. "I won't need medication once my pressure goes down."
Correct Answer: C
Rationale: The correct statement indicating the patient has a good understanding of the treatment regimen is statement C: "I'll take my medication in the morning, every morning." This statement shows that the patient acknowledges the importance of taking their prescribed bumetanide (Bumex) every morning as directed. Consistency in taking the medication as prescribed is crucial for the effective control of hypertension. Statements A and B are unrelated to the treatment regimen and do not address medication adherence. Statement D reflects a misconception that medication can be stopped once blood pressure decreases, which is inaccurate and potentially harmful.
Which is the most common cause of acute renal failure in children?
- A. Pyelonephritis
- B. Tubular destruction
- C. Urinary tract obstruction
- D. Inadequate perfusion
Correct Answer: D
Rationale: Inadequate perfusion, usually due to conditions such as shock or severe dehydration, is the most common cause of acute renal failure in children. Reduced blood flow to the kidneys impairs their ability to function properly and filter waste products from the blood. This can lead to a rapid decline in kidney function and the development of acute renal failure. Other potential causes such as pyelonephritis, tubular destruction, and urinary tract obstruction can also result in acute renal failure, but inadequate perfusion is the most common trigger, especially in pediatric patients.
When assessing the external ear, the nurse palpates a small protrusion of the helix called a Darwin tubercle. The nurse would document this finding as which of the following?
- A. A normal finding
- B. An abnormal finding
- C. A normal finding only in the older adult
- D. An abnormal finding only in the older adult
Correct Answer: A
Rationale: A Darwin tubercle is a small, painless, hereditary nodule located on the helix of the ear. It is a normal anatomical variation and is present in varying degrees in the general population, regardless of age. Therefore, it would be documented as a normal finding during the assessment of the external ear.
A client is admitted for postoperative assessment and recovery after surgery for a kidney tumor. The nurse needs to assess for signs of urinary tract infection. Which of the ff measures can be used to help detect UTI?
- A. Encourage the client to breathe deeply and cough every 2hrs
- B. Monitor temperature every 4hrs
- C. Splint the incision when repositioning the client
- D. Irrigate tubes as ordered CARING FOR CLIENTS WITH DISORDERS OF THE BLADDER AND URETHRA
Correct Answer: B
Rationale: Monitoring temperature every 4 hours is crucial in detecting signs of a urinary tract infection in a postoperative client. An increase in temperature can indicate the presence of an infection, and early identification is essential for prompt treatment. While coughing and deep breathing (Option A) are beneficial for postoperative clients to prevent respiratory complications, they are not directly related to detecting UTI. Splinting the incision (Option C) is important for incisional care but does not specifically help in detecting UTI. Irrigating tubes (Option D) should only be done as ordered by the healthcare provider and is not a routine measure for detecting UTI.
7-year-old Damon has cystitis; which of the following would Nurse Elena expect when assessing the child?
- A. Dysuria
- B. Costovertebral tenderness
- C. Flank pain
- D. High fever
Correct Answer: A
Rationale: Cystitis is inflammation of the bladder, commonly caused by a bacterial infection. In children, symptoms of cystitis often include dysuria, which is painful or difficult urination. This symptom is frequently observed in children with cystitis. Costovertebral tenderness and flank pain are more indicative of kidney involvement (such as in pyelonephritis) rather than just bladder inflammation like in cystitis. High fever may also be present in severe cases of cystitis, but dysuria is the more specific and common symptom associated with this condition in children.