Nokea
The single parent of a 3-year-old child who has just been diagnosed with chickenpox tells the nurse that she cannot afford to stay home with the child and miss work. The parent asks the nurse if some medication will shorten the course of the illness. Which is the most appropriate nursing intervention?
- A. Reassure the parent that it is not necessary to stay home with the child.
- B. Explain that no medication will shorten the course of the illness.
- C. Explain the advantages of the medication acyclovir (Zovirax) to treat chickenpox.
- D. Explain the advantages of the medication VCZ immune globulin (VariZIG) to treat chickenpox.
Correct Answer: B
Rationale: The most appropriate nursing intervention in this scenario is to explain to the parent that no medication will shorten the course of chickenpox. Chickenpox is a viral illness caused by the varicella-zoster virus, and there is no specific treatment to shorten its duration. Antiviral medications like acyclovir are typically reserved for severe cases or for individuals with compromised immune systems. VCZ immune globulin (VariZIG) is used for post-exposure prophylaxis in susceptible individuals who have been exposed to chickenpox and are at high risk for severe disease.
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Alaric was diagnosed with minimal-change nephrotic syndrome; which of the following signs and symptoms are characteristics of the said disorder?
- A. Hypertension, edema, hematuria
- B. Hypertension, edema, proteinuria
- C. Gross hematuria, fever, proteinuria
- D. Poor appetite, edema, proteinuria
Correct Answer: B
Rationale: Minimal-change nephrotic syndrome is a kidney disorder characterized by the presence of proteinuria, which is the excessive loss of protein in the urine. This leads to low levels of protein in the blood, causing edema (swelling) due to fluid accumulation in the tissues. In minimal-change nephrotic syndrome, hypertension (high blood pressure) is not a typical finding. Instead, patients often present with normal blood pressure levels. Additionally, hematuria (presence of blood in the urine) is not a common symptom of this disorder. Therefore, the key signs and symptoms characteristic of minimal-change nephrotic syndrome are edema, proteinuria, and the absence of hypertension.
A patient, age 46, is admitted for observation following an auto accident. He hit the steering wheel and has a chest contusion. Which of the following creates a pericardial friction rub?
- A. Inflamed cardiac tricuspid and mitral valves
- B. Decreased cardiac output c.Increased pulmonary pressures
- C. Rubbing of pericardial and epicardial layers
Correct Answer: C
Rationale: A pericardial friction rub is a harsh grating sound caused by the rubbing of the pericardial and epicardial layers of the heart. This rubbing sound can be heard with a stethoscope and is typically indicative of pericarditis, inflammation of the pericardium (the sac surrounding the heart). In the case of the patient with a chest contusion following an auto accident, the trauma could have led to pericardial inflammation and subsequent pericardial friction rub. The other choices do not directly result in the creation of a pericardial friction rub.
The nurse is teaching parents about prevention of urinary tract infections in children. Which factor predisposes the urinary tract to infection?
- A. Increased fluid intake
- B. Short urethra in young girls
- C. Prostatic secretions in males
- D. Frequent emptying of the bladder
Correct Answer: B
Rationale: One of the factors that predisposes the urinary tract to infection is a short urethra in young girls. The shorter urethra compared to boys makes it easier for bacteria to travel up the urinary tract and cause infections. This anatomical difference in young girls increases their susceptibility to urinary tract infections compared to boys. In boys, the longer length of the urethra provides a natural barrier for bacteria to enter the bladder, reducing the risk of infection.
In which of the ff clients will an MRI scan be contraindicated?
- A. Overweight clients
- B. Clients with metal implants in their body
- C. Clients over the age of 60
- D. Clients with brain tumor CARING FOR CLIENTS WITH CENTRAL AND PERIPHERAL NERVOUS SYSTEM DISORDERS
Correct Answer: B
Rationale: An MRI scan uses strong magnetic fields and radio waves to create detailed images of the body's internal structures. Clients with metal implants in their body, such as pacemakers, artificial joints, or other metallic objects, may experience potential risks and complications during an MRI scan. The strong magnetic field can interact with the metal in the body, causing movement, heating, or potential damage to the surrounding tissues. Hence, it is contraindicated to perform an MRI scan on clients with metal implants to avoid harm and ensure their safety.
The nurse would expect which of the following would be included in the plan of care/
- A. Have the client drink at least 8 glases of water in the first day
- B. Administer NaHCO3 IV as per physician's orders
- C. Continue sodium bicarbonate for nausea
- D. Monitor electrolytes for hypokalemia and hypocalcemia
Correct Answer: D
Rationale: Monitoring electrolytes for hypokalemia (low potassium levels) and hypocalcemia (low calcium levels) is essential in the plan of care for a client. These electrolyte imbalances can be common in cases of dehydration and vomiting, and they can lead to serious complications if not detected and managed promptly. Hypokalemia can cause cardiac arrhythmias and muscle weakness, while hypocalcemia can lead to neuromuscular irritability and seizures. By monitoring electrolyte levels, the nurse can identify any imbalances early and take necessary interventions to prevent adverse outcomes.