Nokea
The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24- month checkup. What criteria should the nurse use in determining the appropriate-size blood pressure cuff? (Select all that apply.)
- A. The cuff is labeled "toddler."
- B. The cuff bladder width is approximately 40% of the circumference of the upper arm.
- C. The cuff bladder length covers 80% to 100% of the circumference of the upper arm.
- D. The cuff bladder covers 50% to 66% of the length of the upper arm.
Correct Answer: B
Rationale: For a 2-year-old boy, the nurse should consider the following criteria in determining the appropriate-size blood pressure cuff:
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The MOST common cause of sleeping difficulty in the first 2 months of life is
- A. gastro-esophageal reflux
- B. colic
- C. formula intolerance
- D. developmentally self-resolving sleeping behavior
Correct Answer: B
Rationale: Colic is a frequent cause of sleep difficulties in young infants.
An adult has been stung by a bee and is in anaphylactic shock. An epinephrine (adrenaline) injection has been given. The nurse would expect which the following if the injection has been effective?
- A. The client's breathing will become easier
- B. The client's blood pressure will decrease
- C. There will be an increase in angiodema
- D. There will be a decrease in the client's level of consciousness
Correct Answer: A
Rationale: An epinephrine (adrenaline) injection is the first-line treatment for anaphylaxis, as it helps to relax the muscles in the airway and improve breathing. This results in the client's breathing becoming easier. Epinephrine also acts to increase blood pressure, while angioedema (swelling) and a decreased level of consciousness are not expected effects of an effective epinephrine injection.
Nurse Kara is giving instructions to an elderly client on diabetic foot care. Which teaching is not part of foot care?
- A. wear comfortable shoes that fit well and protect your feet
- B. trim your toenails straight across and file edges with emery board
- C. wash your feet in hot water to keep feet soft
- D. wear shoes at the beach or on hot pavement
Correct Answer: C
Rationale: Washing your feet in hot water is not recommended as it can actually worsen diabetic foot conditions. Hot water can lead to burns and damage the skin, especially for individuals with reduced sensation in their feet due to diabetes. It is advised to wash feet in warm water instead, avoiding hot temperatures to prevent injuries and complications. The other options provide important aspects of diabetic foot care such as wearing appropriate shoes, trimming toenails carefully, and being mindful of footwear choices to protect the feet.
Which factor most impacts the type of injury a child is susceptible to, according to the child's age?
- A. Physical health of the child
- B. Developmental level of the child
- C. Educational level of the child
- D. Number of responsible adults in the home
Correct Answer: B
Rationale: The developmental level of the child most impacts the type of injury they are susceptible to based on their age. As children grow and develop, their physical abilities, cognitive skills, and understanding of the environment change. Younger children may be more susceptible to injuries related to exploration and lack of awareness of dangerous situations, while older children may be more prone to injuries during physical activities or sports. Understanding the developmental stage of a child is crucial in assessing potential risks and implementing appropriate safety measures to prevent injuries.
A healthy 20-day-old male examination reveals a palpable liver margin below the right costal margin; lab findings: white blood count, 18700/mm3; hemoglobin, 8.8 g/dl; blast cells, 10%; the BEST approach for the management is consistent with acute myeloproliferative disorder
- A. intensive chemotherapy
- B. low dose chemotherapy pulses
- C. bone marrow transplantation
- D. close follow up
Correct Answer: A
Rationale: Intensive chemotherapy is the standard approach for managing acute myeloproliferative disorders.