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The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?
- A. Chronic vessel plaque formation
- B. Pulmonary embolism
- C. Occlusions at the vessel bifurcations
- D. Coronary artery aneurysms
Correct Answer: A
Rationale: The correct answer is chronic vessel plaque formation. Kawasaki Disease affects small and medium-sized blood vessels, leading to progressive inflammation and potential damage to the walls of medium-sized muscular arteries, which can result in coronary artery aneurysms. While other complications such as pulmonary embolism and occlusions at vessel bifurcations can occur in different conditions, for Kawasaki Disease, the primary concern is the development of chronic vessel plaque formation.
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Which response would best assist the chemically impaired client in dealing with issues of guilt?
- A. Addiction usually causes people to feel guilty. Don't worry, it is a typical response due to your drinking behavior.
- B. What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?
- C. Don't focus on your guilty feelings. These feelings will only lead you to drinking and taking drugs.
- D. You've caused a great deal of pain to your family and close friends, so it will take time to undo all the things you've done.
Correct Answer: B
Rationale: The correct response is, 'What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?' This response encourages the client to reflect on their actions, identify sources of guilt, and develop a plan to address and reduce these feelings constructively. Choice A is incorrect as it dismisses the client's guilt as typical, potentially invalidating their emotions. Choice C is incorrect as it suggests avoiding guilty feelings by turning to substance use, which is counterproductive. Choice D is incorrect as it focuses on the negative consequences of the client's actions without offering a constructive way to address and alleviate guilt.
A victim of domestic violence states, 'If I were better, I would not have been beaten.' Which feeling best describes what the victim may be experiencing?
- A. Fear
- B. Helplessness
- C. Self-blame
- D. Rejection
Correct Answer: C
Rationale: The correct answer is self-blame. In this scenario, the victim is attributing the abuse to their own inadequacies or faults, thinking that if they were different, the abuse would not occur. This is a common response seen in victims of domestic violence, where they wrongly internalize the blame for the abuser's actions. Fear (Choice A) is a valid emotion, but in this case, the victim is not expressing fear but rather self-blame. Helplessness (Choice B) is also a common feeling in victims of domestic violence, but in this specific statement, the victim is demonstrating self-blame. Rejection (Choice D) does not accurately reflect the victim's statement and emotional response in the given scenario.
The nurse is teaching parents about the treatment plan for a 2-week-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report
- A. Loss of consciousness
- B. Feeding problems
- C. Poor weight gain
- D. Fatigue with crying
Correct Answer: A
Rationale: The correct answer is 'Loss of consciousness.' While parents should report any concerning observations, they need to call the healthcare provider immediately if the infant experiences a loss of consciousness. This change in alertness may indicate anoxia, which can be life-threatening. Tetralogy of Fallot is a congenital heart defect characterized by four main features: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. Surgery for Tetralogy of Fallot may be delayed or done in stages. Reporting loss of consciousness is crucial due to the potential seriousness of the condition. Feeding problems, poor weight gain, and fatigue with crying are important issues but do not require immediate reporting like loss of consciousness does.
After surgery for an imperforate anus, an infant returns with a red and edematous colostomy stoma. What action should the nurse take based on this finding?
- A. Elevate the buttocks.
- B. Document the findings.
- C. Apply ice immediately.
- D. Call the primary health care provider.
Correct Answer: B
Rationale: A red and edematous colostomy stoma is a common finding immediately after surgery, and these changes are expected to decrease over time. As the stoma heals, it usually becomes pink without signs of abnormal drainage, swelling, or skin breakdown. Therefore, the appropriate action for the nurse is to document these normal findings. Elevating the buttocks, applying ice, or calling the primary health care provider are unnecessary interventions at this stage.
A mother brings her 26-month-old to the well-child clinic. She expresses frustration and anger due to her child's constant saying 'no' and refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?
- A. Trust
- B. Initiative
- C. Independence
- D. Self-esteem
Correct Answer: C
Rationale: In Erikson's theory of development, toddlers struggle to assert independence. They often use the word 'no' even when they mean yes. This stage is called autonomy versus shame and doubt. The child's behavior of saying 'no' and resisting directions reflects the developmental need for independence, not trust (option A), initiative (option B), or self-esteem (option D). Trust is typically associated with early infancy, initiative with preschool age, and self-esteem with later childhood and adolescence.