Tony is to be discharged in the afternoon of the same day after tonsillectomy and adenoidectomy. You, as the RN, will make sure that the family knows to:
- A. offer pureed foods
- B. offer soft foods for a week to minimize discomfort while swallowing
- C. supplement his diet with Vitamin C-rich foods to enhance healing
- D. offer clear liquids for 3 days to prevent irritation
Correct Answer: B
Rationale: After tonsillectomy and adenoidectomy, it is crucial to provide soft foods for a week to minimize discomfort while swallowing. This helps prevent irritation to the surgical site and allows for easier healing. Offering pureed foods (Choice A) may not be necessary as soft foods are usually sufficient. While Vitamin C is beneficial for healing, it is not necessary to supplement it immediately after surgery with Vitamin C-rich juices (Choice C). Clear liquids are typically recommended before surgery and not after, as the focus shifts to soft foods to aid in recovery, making Choice D incorrect.
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Which of the following treatments is not recommended for a child classified with no dehydration?
- A. Administering 1,000 ml to 1,400 ml within 4 hours
- B. Continuing feeding
- C. Allowing the child to take as much fluid as he wants
- D. Returning the child to the doctor if the condition worsens
Correct Answer: B
Rationale: The correct answer is B. Continuing feeding is a recommended treatment for a child classified with no dehydration. This helps maintain the child's nutritional status and supports recovery. Options A, C, and D are appropriate interventions for a child with no dehydration. Option A ensures adequate fluid intake, option C promotes hydration, and option D ensures appropriate follow-up if the condition worsens.
What is a major goal for home care nurses?
- A. Restoring maximum health function.
- B. Promoting the health of populations.
- C. Minimizing the progress of disease.
- D. Maintaining the health of populations.
Correct Answer: A
Rationale: A major goal for home care nurses is restoring maximum health function. This involves helping patients achieve their highest level of health and independence, focusing on individualized care plans tailored to each patient's needs. Choice B, promoting the health of populations, is more aligned with public health nursing rather than home care nursing. Choice C, minimizing the progress of disease, is important but not as comprehensive as restoring maximum health function. Choice D, maintaining the health of populations, is more about preventive care at a population level rather than the individualized care provided by home care nurses.
When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods?
- A. 10-15 seconds
- B. 30-35 seconds
- C. 20-25 seconds
- D. 0-5 seconds
Correct Answer: D
Rationale: During endotracheal suctioning, the nurse should apply suctioning while withdrawing and gently rotating the catheter 360 degrees for a short period of 0-5 seconds. This brief duration helps minimize the risk of hypoxia and trauma to the airway. Choices A, B, and C suggest longer time periods for suctioning, which can increase the risk of complications such as hypoxia, mucosal damage, and the removal of excess amounts of airway secretions.
Myxedema coma is a life-threatening complication of long-standing and untreated hypothyroidism with one of the following characteristics.
- A. Hyperglycemia
- B. Hypothermia
- C. Hyperthermia
- D. Hypoglycemia
Correct Answer: A
Rationale: Myxedema coma is associated with hypothermia, not hyperthermia. Therefore, the correct characteristic of myxedema coma is hypothermia. This condition is a medical emergency that requires prompt recognition and intervention to prevent serious complications. The presence of hyperglycemia is not a defining characteristic of myxedema coma, making choice A the correct answer in this case. Hyperthermia and hypoglycemia are not typically seen in myxedema coma and are not consistent with the clinical presentation of this condition.
Selective inattention is seen in which level of anxiety?
- A. Mild
- B. Moderate
- C. Severe
- D. Panic
Correct Answer: D
Rationale: Selective inattention is a defense mechanism seen in panic-level anxiety. In panic anxiety, individuals may experience selective inattention, where they focus only on specific aspects and ignore others. Mild anxiety does not typically involve selective inattention as individuals can still function effectively. Moderate and severe anxiety may impair attention, but selective inattention is more characteristic of panic-level anxiety.