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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. A client with a suspected left sided heart failure is scheduled to undergo a multigated acquisition scan. Which of the following actions is required before undergoing the test?
- A. Diuretics are administered
- B. Client should avoid fluid intake 6 hours
- C. Client is medicated to relieve cough before the test
- D. Client is administered analgesics
Correct Answer: C
Rationale: Before undergoing a multigated acquisition scan, a client with suspected left sided heart failure should be medicated to relieve cough. Coughing can disrupt the accuracy of the scan results by affecting the heart's movement and leading to motion artifacts. Therefore, it is essential to address any coughing issues before the test to ensure reliable and accurate imaging of the heart's function. The other options, such as administering diuretics, avoiding fluid intake, and administering analgesics, are not directly related to optimizing the imaging quality of the multigated acquisition scan for a client with suspected left sided heart failure.
The nurse is caring for a 32-year old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
- A. Pallor, bradycardia, and reduced pule
- B. Sore tongue, dyspnea, and weight gain
- C. Angina, double vision, and anorexia
- D. Pallor, tachycardia, and a sore tongue
Correct Answer: D
Rationale: Pernicious anemia is a type of megaloblastic anemia caused by the body's inability to absorb vitamin B12, essential for the production of red blood cells. The characteristic findings associated with pernicious anemia include pallor due to decreased red blood cells, tachycardia as the heart compensates for decreased oxygen-carrying capacity, and a sore tongue (glossitis) due to vitamin B12 deficiency affecting the oral mucosa. Therefore, the nurse should expect to find pallor, tachycardia, and a sore tongue when assessing a client with pernicious anemia.
Which is the nurse's best interpretation of this?
- A. Resuscitation is likely to be needed.
- B. Adjustment to extrauterine life is adequate.
- C. Additional scoring in 5 more minutes is needed.
- D. Maternal sedation or analgesia contributed to the low score.
Correct Answer: B
Rationale: The nurse's best interpretation is that the adjustment to extrauterine life is adequate. This can be determined by the Apgar score, which assesses a newborn's well-being shortly after birth. A score of 7-10 indicates that the newborn is adjusting well to life outside the womb, while a score of 4-6 may indicate some difficulties that may require intervention. In this case, the nurse's interpretation suggests that the newborn is doing well in adapting to the new environment.
When should the nurse expect jaundice to be present in a newborn with hemolytic disease?
- A. At birth
- B. During first 24 hours after birth
- C. 24 to 48 hours after birth
- D. 48 to 72 hours after birth
Correct Answer: D
Rationale: In a newborn with hemolytic disease, jaundice typically appears 48 to 72 hours after birth due to the accumulation of bilirubin in the baby's blood. This condition is known as hyperbilirubinemia, which occurs when the liver is still immature and unable to effectively process bilirubin. The breakdown of red blood cells in hemolytic disease leads to an increased production of bilirubin, resulting in jaundice. It is important for healthcare providers to monitor the newborn closely during this time period to ensure appropriate management of the jaundice.
The Foley Family is caring for their youngest child, Justin, who is suffering from tetralogy of Fallot. Which of the following are defects associated with this congenital heart condition?
- A. Aorta exits from the right ventricle, pulmonary artery exits from the left ventricle, and two noncommunicating circulations
- B. Ventricular septal defect, overriding aorta, pulmonic stenosis (PS), and right ventricular hypertrophy
- C. Coarctation of aorta, aortic valve stenosis, mitral valve stenosis, and patent ductus arteriosus
- D. Tricuspid valve atresia, atrial septal defect, ventricular septal defect, and hypoplastic right ventricle
Correct Answer: B
Rationale: Tetralogy of Fallot is a congenital heart condition characterized by four specific defects: