Nokea
The nurse is taking care of a 7-year-old child with herpes simplex virus (type 1 or 2). Which prescribed medication should the nurse expect to be included in the treatment plan?
- A. Corticosteroids
- B. Oral griseofulvin
- C. Oral antiviral agent
- D. Topical and/or systemic antibiotic
Correct Answer: C
Rationale: For the treatment of herpes simplex virus (type 1 or 2) in a 7-year-old child, the nurse should expect the prescribed medication to include an oral antiviral agent. Antiviral medications such as acyclovir, valacyclovir, or famciclovir are commonly used to manage herpes simplex virus infections. These medications help to reduce the severity and duration of symptoms, promote healing of lesions, and prevent future outbreaks. Corticosteroids are not typically used in the treatment of herpes simplex virus infections. Oral griseofulvin is an antifungal medication used to treat fungal infections, not viral infections like herpes simplex virus. Topical and/or systemic antibiotics are used to treat bacterial infections and are not effective against viruses like herpes simplex.
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As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?
- A. I know the hallucinations are parts of the disease
- B. I told her she is wrong and I explained to her what is right
- C. I help her do some tasks he cannot do for himself
- D. Ill turn off the TV when we go to another room
Correct Answer: B
Rationale: Option B, "I told her she is wrong and I explained to her what is right," would require the nurse to give further teaching because it indicates a lack of understanding about how to communicate with a person experiencing hallucinations. People with hallucinations may have a distorted sense of reality, and arguing with them or insisting on what is "right" can be counterproductive. The daughter would benefit from additional education on how to effectively communicate and support her father during episodes of hallucinations.
A client who was diagnosed with type I diabetes mellitus 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level?
- A. Cool, moist skin
- B. Arm and leg trembling
- C. Rapid, thready pulse
- D. Slow, shallow respirations
Correct Answer: B
Rationale: A blood glucose level of 470 mg/dl indicates severe hyperglycemia in a client with type I diabetes mellitus. Arm and leg trembling, known as tremors, is a common symptom associated with high blood glucose levels. Tremors are often a result of the body's stress response to the extreme levels of glucose in the blood. Other common symptoms of hyperglycemia include increased thirst, frequent urination, blurred vision, and fatigue. Cool, moist skin, rapid, thready pulse, and slow, shallow respirations are not typically associated with hyperglycemia and are more indicative of other conditions or clinical situations.
What does the American Academy of Pediatrics recommend as the best form of newborn nutrition?
- A. Exclusive breastfeeding until age 2 months.
- B. Exclusive breastfeeding until age 6 months.
- C. Commercially prepared newborn formula for 1 year.
- D. Commercially prepared newborn formula until age 4 to 6 months.
Correct Answer: B
Rationale: The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for the first 6 months of a baby's life. Breast milk provides all the necessary nutrients and antibodies that a baby needs for healthy growth and development during this crucial period. Breastfeeding also offers long-term health benefits for both the baby and the mother. It is important for mothers to receive support and education to establish and maintain successful breastfeeding. After the first 6 months, the AAP recommends continuing breastfeeding while introducing appropriate solid foods until at least 12 months of age, or longer if both the mother and baby are willing and able.
The patient is dangling at the bedside and states, "Oh, my stomach is tearing open." Which of the following actions should the nurse immediately take when dehiscence occurs?
- A. Have patient sit upright in a chair.
- B. Have patient lie down.
- C. Slow IV fluids.
- D. Obtain a sterile suture set.
Correct Answer: B
Rationale: When dehiscence, which is the separation of the layers of a surgical incision, occurs in a patient, it is important to have the patient lie down. This position will help decrease intra-abdominal pressure and reduce the risk of further complications. Having the patient sit upright in a chair can increase intra-abdominal pressure, worsening the dehiscence. Slowing IV fluids may be necessary to prevent fluid overload in certain situations, but it is not the immediate action required when dehiscence occurs. Obtain a sterile suture set may eventually be needed, but the priority in this situation is to stabilize the patient by having them lie down.
A hospitalized child with minimal change nephrotic syndrome is receiving high doses of prednisone. Which is an appropriate nursing goal related to this?
- A. Prevent infection
- B. Stimulate appetite
- C. Detect evidence of edema
- D. Ensure compliance with prophylactic antibiotic therapy
Correct Answer: C
Rationale: Nephrotic syndrome is characterized by the presence of edema due to loss of protein in the urine. One of the nursing goals in managing a child with minimal change nephrotic syndrome receiving high doses of prednisone is to monitor for the development or worsening of edema. Detecting evidence of edema is important as it can help in assessing the effectiveness of treatment, such as monitoring the response to prednisone therapy and adjusting the treatment plan accordingly. Monitoring for edema can also help in preventing complications associated with fluid overload, such as hypertension and respiratory distress. Therefore, detecting evidence of edema is an appropriate nursing goal in this scenario.