Nokea
The nurse is using the FLACC scale to rate the pain level in a 9-month-old. Which is the nurse's best response to the father's question of what the FLACC scale is?
- A. It estimates a child's level of pain utilizing vital sign information.
- B. It estimates a child's level of pain based on parents' perception.
- C. It estimates a child's level of pain utilizing behavioral and physical responses.
- D. It estimates a child's level of pain utilizing a numeric scale from 0 to 5.
Correct Answer: C
Rationale: The FLACC scale uses observable behavioral and physical responses (facial expression, leg movement, activity, cry, and consolability) to estimate pain.
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An adolescent with new-onset diabetes is struggling with 'daytime accidents.' What is this condition called?
- A. Primary enuresis.
- B. Secondary enuresis.
- C. Diurnal enuresis.
- D. Nocturnal enuresis.
Correct Answer: C
Rationale: Secondary enuresis is the recurrence of incontinence in a child who had previously achieved bladder control.
Which of the ff should qualify as an abnormal result in a Romberg test?
- A. Hypotension
- B. Swaying, losing balance, or arm drifting
- C. Sneezing and wheezing
- D. Excessive cerumen in the outer ear
Correct Answer: B
Rationale: During a Romberg test, the individual is asked to stand with feet together, arms at sides, and eyes closed. The tester then observes for swaying, losing balance, or arm drifting, which are signs of a positive Romberg test, indicating a potential issue with proprioception or vestibular function. Hypotension (choice A) refers to low blood pressure and is not directly assessed during a Romberg test. Sneezing and wheezing (choice C) are unrelated symptoms. Excessive cerumen in the outer ear (choice D) does not affect the results of a Romberg test focused on balance and proprioception.
Nurse Nancy also gives a lecture at the community health center about the diet for patients with ulcerative colitis. Which one is appropriate?
- A. high calorie, low protein
- B. low fat, high fiber
- C. high protein, low residue
- D. low sodium, high carbohydrate
Correct Answer: C
Rationale: Patients with ulcerative colitis usually benefit from a high protein, low residue diet. A high protein diet helps promote tissue healing and repair. Low residue foods are preferred to reduce mechanical irritation to the inflamed colon. This combination can help manage symptoms and promote overall gut health for individuals with ulcerative colitis. High calorie, low protein (Option A) may not provide adequate nutrient density and healing support. Low fat, high fiber (Option B) may exacerbate symptoms and increase gastrointestinal discomfort. Low sodium, high carbohydrate (Option D) may not address the specific needs of patients with ulcerative colitis.
A child with thalassemia was given deferoxamine (Desferal); which of the following should alert the nurse to notify the physician?
- A. Decreased hearing
- B. Hypertension
- C. Red urine
- D. Vomiting
Correct Answer: A
Rationale: Deferoxamine is a chelating agent used to treat iron overload in patients such as those with thalassemia. One of the serious side effects of deferoxamine is ototoxicity, which can manifest as decreased hearing or ringing in the ears. Therefore, if a child with thalassemia who is taking deferoxamine experiences a decrease in hearing, the nurse should promptly notify the physician for further evaluation and possible adjustment of the treatment plan to prevent further hearing damage. Hypertension, red urine, and vomiting are possible side effects of deferoxamine, but decreased hearing is the most concerning side effect that requires immediate attention due to the risk of permanent damage.
Which of the following conditions is suspected?
- A. Anemia
- B. Rheumatic arthritis
- C. Leukemia
- D. Systematic Lupus Erythematosus (SLE)
Correct Answer: C
Rationale: Leukemia is a type of cancer that affects the blood and bone marrow, leading to an overproduction of abnormal white blood cells. The symptoms of leukemia can include fatigue, weakness, weight loss, frequent infections, fever, bruising or bleeding easily, and bone pain. Given the vague presenting symptoms and the potential involvement of multiple bodily systems, leukemia is a condition that should be suspected and investigated further. Anemia, rheumatic arthritis, and systematic lupus erythematosus can also present with some similar symptoms, but for the given scenario, leukemia is the most probable condition to suspect.