Nokea
The nurse is talking with the family of an 18 months-old newly diagnosed with retinoblastoma. A priority in communicating with the parents is
- A. Discuss the need for genetic counseling
- B. Inform them that combined therapy is seldom effective
- C. Prepare for the child's permanent disfigurement
- D. Suggest that total blindness may follow surgery
Correct Answer: A
Rationale: Discuss the need for genetic counseling. The hereditary aspects of this disease are well documented. While the parents focus on the needs of this child, they should be aware that the risk is high for future offspring.
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The nurse is reinforcing discharge instructions for the parents of a 4-year-old client with heart failure. What statement made by the parents indicates a need for further teaching?
- A. We will hold the dose if our child’s heart rate is above 90/min.
- B. We will not give a second dose if our child vomits after the first dose.
- C. We will not mix the medication with other foods or liquids.
- D. We will report symptoms of nausea and vomiting to our health care provider.
Correct Answer: A
Rationale: Holding heart failure medication (e.g., digoxin) for a heart rate above 90/min is incorrect for a 4-year-old, as their normal heart rate is 80-120/min; the threshold is typically lower (e.g., <60/min). Not repeating a dose after vomiting, avoiding mixing with food, and reporting nausea/vomiting are correct.
Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a client?
- A. 0.9% sodium chloride
- B. 5% dextrose in water solution
- C. sterile water
- D. Heparin sodium
Correct Answer: A
Rationale: 0.9% sodium chloride (normal saline) is isotonic and compatible with blood, preventing cell lysis or clotting during IV flushing. The other solutions are inappropriate for this purpose. Pharmacological Therapies
An elderly female is admitted with a fractured right femoral neck. Which assessment finding is expected?
- A. Free movement of the right leg
- B. Abduction of the right leg
- C. Internal rotation of the right hip
- D. Shortening of the right leg
Correct Answer: D
Rationale: The symptoms of this fracture include shortened, adducted, and external rotation. Answer A is incorrect because the patient usually is unable to move the leg due to pain. Answer B is incorrect because the symptom is adduction, not abduction. Answer C is wrong because it's external rotation, not internal rotation.
A client is admitted with suspected pheochromocytoma. The physiological alteration associated with pheochromocytoma is:
- A. An extreme elevation in blood pressure
- B. Petechial rash across the chest and axilla
- C. White flecks in the iris
- D. Yellow creases at the nasolabial folds
Correct Answer: A
Rationale: Pheochromocytoma causes catecholamine release, leading to extreme hypertension . Rash , iris flecks , and nasolabial creases are not associated.
The nurse enters the room of an adult who is having a grand mal seizure. Which initial action is appropriate?
- A. Put a padded tongue blade in the client's mouth.
- B. Restrain the client.
- C. Turn the client's head to the side.
- D. Call the physician immediately.
Correct Answer: C
Rationale: Turning the head to the side during a seizure prevents airway obstruction by saliva or vomit, prioritizing safety, unlike tongue blades (risk injury), restraints, or immediate physician calls.