Nokea
The nurse should expect a client with hypothyroidism to report which health concerns?
- A. Increased appetite and weight loss
- B. Nervousness and tremors
- C. Puffiness of the face and hands
- D. Thyroid gland swelling
Correct Answer: C
Rationale: Hypothyroidism is characterized by an underactive thyroid gland that does not produce enough thyroid hormone. This hormonal imbalance can lead to symptoms such as slow metabolism, weight gain, fatigue, cold intolerance, constipation, and puffiness of the face and hands. The slowed metabolic rate can also cause fluid retention, resulting in the characteristic puffiness associated with hypothyroidism. Increased appetite and weight loss are not typical symptoms of hypothyroidism, as the condition is more commonly associated with weight gain. Nervousness and tremors are more indicative of hyperthyroidism, where the thyroid gland is overactive. Thyroid gland swelling, known as goiter, can occur in various thyroid disorders but is not specific to hypothyroidism.
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Kimberly, age 3 years, is being admitted for about 1 week of hospitalization. Her parents tell the nurse that they are going to buy her "a lot of new toys, because she will be in the hospital." The nurse's reply should be based on an understanding of which concept?
- A. New toys make hospitalization easier.
- B. New toys are usually better than older ones for children of this age.
- C. At this age, children often need the comfort and reassurance of familiar toys from home.
- D. Buying new toys for a hospitalized child is a maladaptive way to cope with parental guilt.
Correct Answer: C
Rationale: The correct response is based on the understanding that at the age of 3, children often find comfort and reassurance in familiar toys from home. This familiarity can help them cope with the stress and unfamiliar environment of being hospitalized. Introducing new toys may not provide the same level of comfort and may even add to the child's sense of disorientation during their stay in the hospital. It is essential to prioritize the child's emotional well-being and provide them with familiar items that can offer a sense of security during their hospitalization.
What is the role of a nurse during scratch test to detect allergies?
- A. Applying the liquid test antigen
- B. Determining the type of allergy
- C. Measuring the length and width of the
- D. Documenting the findings raised wheal
Correct Answer: A
Rationale: During a scratch test to detect allergies, one of the key roles of a nurse is to apply the liquid test antigen onto the patient's skin. The liquid test antigen contains small amounts of common allergens that could trigger a reaction in individuals who are allergic to them. By applying the test antigen onto the skin and creating small scratches or pricks, the nurse can observe if the patient develops a raised, red, itchy bump called a wheal at the site of the allergen exposure. This helps in identifying specific allergies and determining the appropriate treatment plan for the patient.
Mr. and Mrs. Smith's child has hemophilia; which of the following actions would you instruct them to avoid?
- A. Immobilizing the joint
- B. Lowering the injured area
- C. Applying cold to the area
- D. Applying pressure
Correct Answer: C
Rationale: Hemophilia is a condition where the blood fails to clot properly. Applying cold to the area can cause vasoconstriction (narrowing of blood vessels) which may slow down the blood flow and exacerbate the bleeding in individuals with hemophilia. Therefore, instructing Mr. and Mrs. Smith to avoid applying cold to the area of injury is crucial in order to prevent further complications.
The nurse is taking care of a 2-year-old child with a macule skin lesion. Which clinical finding should the nurse expect to assess with this type of lesion?
- A. Flat, nonpalpable, and irregularly shaped lesion that is greater than 1 cm in diameter
- B. Heaped-up keratinized cells, flaky exfoliation, irregular, thick or thin, dry or oily, varied in size
- C. Flat, brown mole less than 1 cm in diameter
- D. Elevated, flat-topped, firm, rough, superficial papule greater than 1 cm in diameter
Correct Answer: A
Rationale: A macule is a flat, nonpalpable, and discolored area on the skin that is less than 1 cm in diameter. This type of skin lesion is typically characterized by a change in color without any change in texture or thickness of the skin. The clinical finding associated with a macule is a flat, nonpalpable lesion that is smaller in size (less than 1 cm) and regularly shaped. Therefore, the nurse should expect to assess a flat, nonpalpable, and irregularly shaped lesion that is greater than 1 cm in diameter with a different type of skin lesion, not a macule.
Which is a major complication in a child with chronic renal failure?
- A. Hypokalemia
- B. Metabolic alkalosis
- C. Water and sodium retention
- D. Excessive excretion of blood urea nitrogen
Correct Answer: C
Rationale: A major complication in a child with chronic renal failure is water and sodium retention, leading to fluid overload and hypertension. Because the kidneys are not functioning properly, they are unable to regulate fluid and sodium levels in the body effectively. This can result in edema, increased blood pressure, and potential heart complications. Monitoring and managing fluid and sodium intake are essential in managing this complication in children with chronic renal failure.