Nokea
The nurse observes the temperature record of a client and relates the fever to the brain infection the client currently has. The nurse knows that a high temperature may lead to an increased cerebral irritation. Which of the ff measures can help the nurse control the clients body temperature? Choose all that apply
- A. Providing tepid sponge bath
- B. Applying ice packs
- C. Administering prescribed antipyretics
- D. Keeping the room temperature warm
Correct Answer: A
Rationale: A. Providing tepid sponge bath: This measure helps to gradually lower the body temperature by promoting heat loss through evaporation. It is a safe and effective way to cool down someone with a fever.
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Which of the ff signs may be revealed by a visual examination in a client with tonsillar infection if group A streptococci is the cause?
- A. White patches on the tonsils
- B. Hypertrophied tonsils
- C. Hemorrhage in the tonsils
- D. Bleeding in the tonsils
Correct Answer: A
Rationale: The presence of white patches on the tonsils is a visual sign that may be revealed by a visual examination in a client with a tonsillar infection caused by group A streptococci. These white patches are known as exudates and can be a characteristic feature of streptococcal tonsillitis. These exudates may range in appearance from small white spots to larger patches that cover the tonsils. Additionally, other signs commonly associated with streptococcal tonsillitis may include swollen and red tonsils, fever, sore throat, and sometimes swollen lymph nodes in the neck. It is important to note that definitive diagnosis often requires laboratory testing such as a rapid strep test or throat culture to confirm the presence of group A streptococci.
Building a tower by a 22-month-old child requires
- A. visual-motor coordination
- B. uses objects and actions in combination
- C. gross motor to solve problems
- D. fine motor and symbolic thought
Correct Answer: D
Rationale: At this age, building a tower involves fine motor skills and symbolic thinking.
A 3-year-old attends her grandfather's funeral. Her parents told her he is in heaven with God. Which statement best describes her understanding of spirituality?
- A. The body is here, and the spirit is in heaven.
- B. He is in heaven. Is this heaven?
- C. She will think that because she can see his body, he must still be here.
- D. He won't need his body in heaven.
Correct Answer: C
Rationale: Three-year-olds are literal thinkers; if they see a body, they may assume that the person is still present.
A 2-year-old child is being evaluated for a right flank mass; radiological appearance is consistent with rupture of Wilms tumor. The BEST therapeutic approach for this child is
- A. radiotherapy
- B. concomitant chemotherapy-radiotherapy
- C. another surgery
- D. observation
Correct Answer: B
Rationale: Concomitant chemotherapy and radiotherapy are essential to manage ruptured Wilms tumor and reduce the risk of dissemination.
A baby, exhibiting no obvious signs of congestive heart failure, has been diagnosed with a small ventricular septal defect. Which of the following information should the nurse explain to the baby's parents?
- A. The baby will likely need open-heart surgery within a week.
- B. The defect will likely close without therapy.
- C. The defect likely developed early in the second trimester.
- D. The baby will likely be placed on high-calorie formula.
Correct Answer: B
Rationale: The nurse should explain to the baby's parents that the ventricular septal defect will likely close without therapy. Small ventricular septal defects have a high likelihood of closing on their own as the child grows. Surgical intervention is usually not necessary for small defects, especially when the baby does not exhibit signs of congestive heart failure. It is important for the parents to be aware of the natural course of the defect and to follow up with the healthcare provider for monitoring and management.