Nokea
The parent of a 3-year-old with suspected Wilms tumor says, 'How could I have missed a lump this big?' Which is the best response?
- A. Don't be hard on yourself; it's easy to miss something growing slowly.
- B. I understand you're upset; earlier detection might have improved prognosis.
- C. It takes a trained professional to notice such a lump.
- D. This tumor grows rapidly and may not have been noticeable just a few days ago.
Correct Answer: D
Rationale: Wilms tumor can grow very quickly, so a lump that was not evident previously may become noticeable in a short period.
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The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?
- A. Refer for immediate medical evaluation.
- B. Continue assessment to determine cause of neck pain.
- C. Ask parent when neck was injured.
- D. Record "head lag" on assessment record, and continue assessment of child.
Correct Answer: A
Rationale: Referring the child for immediate medical evaluation is the most appropriate action in this scenario. The symptoms described, including hyperextension of the head (opisthotonos) with pain on flexion, are concerning for meningitis, a serious infection that can rapidly progress and lead to serious complications if not treated promptly. Seeking immediate medical intervention is crucial to assess and manage the child's condition effectively. Continuing with the assessment or asking about a neck injury is not recommended as the priority is to address the potential medical emergency. Recording the "head lag" without taking immediate action could delay necessary medical treatment.
When the LPN is assisting the patient to use an incentive spirometer, which of the following actions by the patient indicates that the patient needs further teaching on how to use the spirometer?
- A. Taking two normal breaths before use.
- B. Sitting upright before use.
- C. Inhaling deeply to reach target.
- D. Exhaling deeply to reach target.
Correct Answer: D
Rationale: When using an incentive spirometer, the patient should inhale deeply to reach the target volume indicated by the marker. Exhaling deeply does not achieve the objective of the incentive spirometer, which is to encourage deep inhalation. If the patient exhales deeply to reach the target, further teaching and clarification about the proper technique of using the spirometer are needed. The correct technique involves inhaling deeply to expand the lungs and help improve lung function.
Mr. Reyes is extremely confused. The nurse provide new information slowly and in small amounts because;
- A. Confusion or delirium can be a defense against further stress
- B. Destruction of brain cells has occurred, interrupting mental activity
- C. Teaching based on information progressing from the simple to the complex
- D. A minimum of information should be given, since he is unaware of surrounding
Correct Answer: A
Rationale: Providing new information slowly and in small amounts to a confused individual, like Mr. Reyes, is important because confusion or delirium can be a defense mechanism against further stress. By giving information gradually, it allows the individual to better absorb and process the information without becoming overwhelmed, which can further exacerbate their confusion. This approach also helps reduce the risk of causing additional stress or agitation in the individual, thus promoting a more conducive environment for cognitive processing and understanding.
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.
The nurse is caring for a newborn with respiratory distress syndrome. The newborn has an endotracheal tube. Which statement describes nursing considerations related to suctioning?
- A. Suctioning should not be carried out routinely.
- B. Newborn should be in Trendelenburg position for suctioning.
- C. Routine suctioning, usually every 15 minutes, is necessary.
- D. Frequent suctioning is necessary to maintain patency of bronchi.
Correct Answer: A
Rationale: Suctioning should not be carried out routinely in a newborn with respiratory distress syndrome and an endotracheal tube. Routine, frequent suctioning can lead to airway trauma, damage to mucous membranes, and increased risk of infection. Suctioning should only be performed when there are clinical indications such as visible secretions or signs of respiratory distress. Each suctioning event should be carefully assessed and performed with gentle technique to minimize potential harm to the newborn's delicate airway.