Nokea
The nurse understands that the pathophysiology of a thermal injury includes (Select All that Apply):
- A. Hematuria
- B. Edema
- C. Hypovolemia
- D. Anemia
Correct Answer: B,C
Rationale: The correct answers are B: Edema and C: Hypovolemia. Edema occurs due to increased capillary permeability after a thermal injury, leading to fluid leakage into tissues. Hypovolemia results from fluid shift out of the blood vessels into the injured tissues, causing decreased blood volume. Hematuria (A) is not typically associated with thermal injuries. Anemia (D) is a decrease in the number of red blood cells or hemoglobin, not a direct result of thermal injury.
You may also like to solve these questions
Fentanyl 30mcg IV is ordered. The vial contains 0.05mg/ml. How many ml should the nurse administer?
- A. 0.3 ml
- B. 3 ml
- C. 0.06 ml
- D. 0.6 ml
Correct Answer: D
Rationale: To calculate the amount of Fentanyl to administer, first convert 30mcg to mg by dividing by 1000 (30mcg = 0.03mg). Then, divide the dose by the concentration of the vial (0.03mg ÷ 0.05mg/ml = 0.6ml). The correct answer is D (0.6ml). Choice A (0.3ml) is incorrect because it doesn't account for the correct dosage calculation. Choice B (3ml) is incorrect as it is too high, leading to potential overdose. Choice C (0.06ml) is incorrect as it miscalculates the dosage based on the vial concentration.
When preparing your pediatric patient for his cardiac assessment, which element would you start with for the assessment?
- A. Assess peripheral pulses
- B. Auscultate heart rate and rhythm
- C. Evaluate chest rise
- D. Palpate liver margins
Correct Answer: B
Rationale: The correct answer is B: Auscultate heart rate and rhythm. This is the first step in a pediatric cardiac assessment because it provides crucial information about the heart's function. Listening to the heart helps identify any abnormalities in heart sounds, such as murmurs or irregular rhythms, which can indicate underlying cardiac issues. Assessing peripheral pulses (choice A) may be important but comes after evaluating the heart. Evaluating chest rise (choice C) is important for respiratory assessment, not specifically for cardiac assessment. Palpating liver margins (choice D) is more relevant for assessing hepatomegaly, not typically the initial step in a cardiac assessment.
Which is descriptive of attention deficit hyperactivity disorder (ADHD)?
- A. Manifestations of ADHD are typically so bizarre that the diagnosis is easy
- B. Manifestations of ADHD affect all aspects of the child's life but are most obvious in the classroom
- C. Manifestations of ADHD such as learning disabilities eventually disappear by adulthood
- D. Manifestations of ADHD must always be present and are required to receive a positive diagnosis
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Manifestations of ADHD affect all aspects of the child's life but are most obvious in the classroom. ADHD symptoms impact academic performance, social interactions, and behavior in various settings. Children with ADHD often struggle with impulse control, hyperactivity, and inattention, leading to challenges in the classroom environment. This choice acknowledges the pervasive nature of ADHD symptoms while highlighting the prominent impact on the child's educational experience.
Summary of other choices:
A: Incorrect - Manifestations of ADHD are not necessarily bizarre, and the diagnosis is often complex due to overlapping symptoms with other conditions.
C: Incorrect - Learning disabilities and ADHD are separate conditions, and ADHD symptoms may persist into adulthood without necessarily disappearing.
D: Incorrect - While consistent manifestations are a key diagnostic criterion, ADHD symptoms can fluctuate in intensity and may still be present without being constant.
A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse recommend to promote independence in eating?
- A. Banana Slices
- B. Grapes
- C. Hot dog
- D. Popcorn
Correct Answer: A
Rationale: The correct answer is A: Banana Slices. Toddlers can easily pick up banana slices with their fingers, promoting independence in self-feeding. Bananas are soft and easy to chew, reducing the risk of choking compared to grapes, hot dogs, and popcorn, which are common choking hazards for young children. Grapes and hot dogs can easily get stuck in a toddler's throat due to their shape and texture. Popcorn is a choking hazard due to its hard and small size. Therefore, recommending banana slices is the safest and most developmentally appropriate choice for promoting independence in eating for a 2-year-old toddler.
When caring for a newborn with Down syndrome, what should the nurse be aware is the most common congenital anomaly associated with Down syndrome?
- A. Diabetes insipidus
- B. Pyloric stenosis
- C. Congenital heart disease
- D. Congenital hip dysplasia
Correct Answer: C
Rationale: The correct answer is C: Congenital heart disease. Down syndrome is commonly associated with congenital heart defects, such as atrioventricular septal defects or ventricular septal defects. This is important for the nurse to be aware of because these heart anomalies can impact the newborn's health and require monitoring or intervention.
Choice A: Diabetes insipidus is not a common congenital anomaly associated with Down syndrome.
Choice B: Pyloric stenosis is not typically associated with Down syndrome.
Choice D: Congenital hip dysplasia is not a common anomaly seen with Down syndrome.
In summary, the nurse should prioritize monitoring for congenital heart disease in a newborn with Down syndrome due to its high prevalence and potential impact on the baby's health.