Nokea
The pediatric nurse cares for a patient who has undergone a hydrocele repair. While assessing the patient, the nurse notices that the scrotum is swollen and discolored. These findings are:
- A. abnormal, and indicate the need for a cool compress.
- B. abnormal, and indicate the presence of hemorrhaging.
- C. normal, and indicate no need for intervention.
- D. normal, and indicate the need for a position change.
Correct Answer: C
Rationale: Swelling and discoloration after hydrocele repair are typically normal postoperative findings and do not require immediate intervention unless excessive or worsening.
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Which of the ff nursing interventions is required when caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion?
- A. Restrict fluid intake
- B. Ensure that the client avoids prolonged sitting
- C. Position lower extremities below level of heart
- D. Instruct the client to avoid leg exercises
Correct Answer: C
Rationale: When caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion, it is important to promote optimal blood flow to the tissues. Positioning the lower extremities below the level of the heart helps to facilitate venous return and improve circulation to the extremities. This position helps reduce the workload on the heart and promotes better perfusion to the tissues, ultimately aiding in the prevention of complications related to ineffective tissue perfusion. The other options (A. Restrict fluid intake, B. Ensure that the client avoids prolonged sitting, D. Instruct the client to avoid leg exercises) are not directly related to improving tissue perfusion and may not be appropriate interventions in this situation.
A client becomes upset when the physician diagnoses diabetes mellitus as the cause of current signs and symptoms. The client tells the nurse, "This must be a mistake. No one in my family has ever had diabetes." Based on this statement, the nurse suspects the client is using which coping mechanism?
- A. Denial
- B. Anger
- C. Withdrawal
- D. Resolution
Correct Answer: A
Rationale: The client's response of stating that diabetes cannot be possible because it is not prevalent in the family indicates that the client is using the coping mechanism of denial. Denial is a common defense mechanism where individuals refuse to accept reality or facts that are too uncomfortable for them to acknowledge. In this situation, the client is denying the diagnosis of diabetes as a way to cope with the distressing news, hoping that it may not be true because it has not affected their family members in the past. Recognizing this coping mechanism is important for the nurse to provide support and education to help the client come to terms with the diagnosis and start managing the condition effectively.
When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. What is the best explanation for this?
- A. Some form of cancer
- B. Local scalp infection common in children
- C. Infection or inflammation distal to the site
- D. Infection or inflammation close to the site
Correct Answer: D
Rationale: In this case, the tenderness, enlargement, and warmth of the child's cervical lymph nodes are likely due to an infection or inflammation that is close to the site. When lymph nodes are palpated and found to be tender, enlarged, and warm, it often indicates that the lymphatic system is responding to an infection or inflammation in the nearby area. The lymph nodes are part of the body's immune system and can become enlarged and tender as they work to fight off the infection. In this scenario, the most likely explanation is an infection or inflammation located near the cervical lymph nodes.
At about what age does the Babinski sign disappear?
- A. 4 months
- B. 6 months
- C. 1 year
- D. 2 years
Correct Answer: D
Rationale: The Babinski sign is a reflex response in infants where their big toe moves upward and the other toes fan out when the sole of the foot is stroked. This reflex is normally present in infants up to around 2 years of age. By the age of 2, the nervous system has matured, and the Babinski sign disappears as the child's motor pathways develop and the reflex becomes suppressed. After the age of 2, the presence of the Babinski sign can indicate neurological issues, so its absence beyond this age is considered normal.
The birthweight usually quadruples by the age of
- A. 1.5 yr
- B. 2 yr
- C. 2.5 yr
- D. 3 yr
Correct Answer: B
Rationale: Birthweight typically quadruples by 2 years of age.