Nokea
Theresa, a mother with a 2-year-old daughter, asks, 'At what age can I start taking my daughter's blood pressure as a routine procedure, since hypertension is common in our family?' What would your answer be?
- A. At 2 years old, you may
- B. As early as 1 year old
- C. When she's 3 years old
- D. When she's 6 years old
Correct Answer: D
Rationale: Regular blood pressure checks generally start from age 3, but in the case of a family history of hypertension, they should start when the child is around 6 years old. This is because the readings will be more reliable and indicative of the child's health condition at this age. The other options are incorrect because they suggest earlier ages for routine blood pressure checks. While blood pressure can be measured at any age, it is not typically included as part of a routine health check-up for very young children unless there are specific health concerns.
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If it is determined that a child is being physically abused by a parent, what would be the most important goal for the nurse to establish with the family?
- A. The child and any siblings will reside in a secure environment
- B. The family will feel at ease in their relationship with the counselor
- C. The family will gain insight into their abusive behavior patterns
- D. The mother will learn to apply verbal discipline with her children
Correct Answer: A
Rationale: The primary objective when dealing with cases of child abuse is to ensure the safety of the child and any siblings. This means creating a secure environment free from harm, which is why choice 'A' is the correct answer. While choices 'B', 'C', and 'D' might be subsequent steps in a comprehensive plan to deal with the situation, they are not the immediate priority. Understanding abusive behavioral patterns or improving the relationship with the counselor will not directly lead to the child's safety. Likewise, teaching the mother to apply verbal discipline doesn't guarantee the child's safety if the abusive behavior continues. Therefore, these options are not the most important initial goal.
All of the following are instructions for proper foot care to be given to a client with peripheral vascular disease caused by diabetes. Which one is not?
- A. Trim nails using a nail clipper
- B. Apply cornstarch to the foot
- C. Always check the temperature of the water before bathing
- D. Use canvas shoes
Correct Answer: A
Rationale: The correct answer is 'A', which says trim nails using a nail clipper. This is incorrect because patients with peripheral vascular disease, particularly those caused by diabetes, should not trim their nails themselves due to the risk of injury, infection, and poor wound healing. The other options, 'B', 'C', and 'D', are correct advice for diabetic foot care. Applying cornstarch can help keep the feet dry and prevent fungal infections. Checking the water temperature before bathing can prevent burns, as patients with peripheral vascular disease often have decreased sensation in their feet. Wearing canvas shoes can improve foot ventilation and reduce the risk of foot ulcers and infections.
During blood administration, what is essential for the nurse to do in order to carefully monitor for adverse reactions?
- A. Stay with the client for the first 15 minutes of blood administration
- B. Stay with the client for the entire period of blood administration
- C. Run the infusion at a faster rate during the first 15 minutes
- D. Inform the client to notify the staff immediately for any adverse reaction
Correct Answer: A
Rationale: In the context of blood administration, it's crucial for the nurse to stay with the client for the first 15 minutes. This is because most adverse reactions are likely to occur within this initial period. Monitoring the client closely during this time allows for immediate detection and response to any potential reactions. Choice B, staying with the client for the entire period of blood administration, is not typically feasible or necessary, although regular checks should be conducted. Running the infusion at a faster rate during the first 15 minutes (Choice C) is incorrect as this can actually increase the risk of adverse reactions. Informing the client to notify the staff immediately for any adverse reaction (Choice D) is an important practice, but it is not the most direct way for the nurse to monitor for adverse reactions.
Which type of bath would you recommend for a patient experiencing pruritus?
- A. Saline
- B. Colloidal (oatmeal)
- C. Water
- D. Sodium bicarbonate
Correct Answer: B
Rationale: The best choice for a pruritus (itching) patient is a colloidal (oatmeal) bath, as it is known for its soothing effect on itchy, irritated skin. Saline, water, and sodium bicarbonate baths may not provide the same level of relief for pruritus. The nursing care should involve comprehensive assessments and appropriate interventions to optimize patient outcomes. In this case, a colloidal bath is the most suitable intervention for a patient experiencing pruritus.
What does a QRS Complex represent in an ECG reading?
- A. Atrial depolarization
- B. Ventricular repolarization
- C. Ventricular depolarization
- D. End of ventricular depolarization
Correct Answer: C
Rationale: The QRS Complex in an ECG reading represents ventricular depolarization, which is the process of the heart's ventricles preparing to contract by changing the electrical charge in the cell, hence choice 'C' is the correct answer. Choice 'A' is incorrect because atrial depolarization is represented by the P wave in an ECG reading, not the QRS Complex. Choice 'B' is incorrect as ventricular repolarization is depicted by the T wave, not the QRS Complex. Finally, choice 'D' is also incorrect because the QRS Complex is not the end of ventricular depolarization, but the process itself.