Nokea
What are the essential nursing actions that should be taken for a client with immune system disorder? Choose all that apply
- A. Follow agency guidelines to control
- B. Review drug references
- C. Advise the client on modifying the
- D. Monitor client for depression home environment
Correct Answer: E
Rationale: Clients with immune system disorders may receive treatments such as immunoglobulin therapy or biologic agents through infusions. It is essential for the nurse to monitor the client for infusion reactions, which can include symptoms such as fever, chills, nausea, and allergic reactions. Early recognition of infusion reactions is crucial for prompt intervention to prevent complications and ensure the client's safety. By closely monitoring the client during and after the infusion, the nurse can detect and address any adverse reactions promptly.
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For children receiving steroid therapy, which of the following regimens is most appropriate for perioperative management?
- A. Prednisone 1 mg/kg given 24 and 12 hours before surgery
- B. Dexamethasone 0.6 mg/kg IV given 24 and 12 hours before surgery
- C. Hydrocortisone 5 mg/kg IV given 24 and 12 hours before surgery
- D. Methylprednisolone 10 mg/kg IV given 24 and 12 hours before surgery
Correct Answer: C
Rationale: Hydrocortisone is commonly used for perioperative steroid coverage due to its mineralocorticoid and glucocorticoid effects.
for pain management. When applying a new system, the nurse should:
- A. Press the system in place for 30 to 60 seconds.
- B. Choose a site on the lower torso.
- C. Shave the application site before use.
- D. Apply the system immediately after removal from a package.
Correct Answer: B
Rationale: When applying a new system for pain management, it is recommended to choose a site on the lower torso. This area is often a suitable location for applying transdermal pain medication patches because it tends to have fewer hair follicles, making it easier for the patch to adhere properly and be absorbed effectively. The lower torso also typically provides a discreet location for patch placement, helping to maintain patient privacy and comfort.
all the following are true about seizures disorders except :
- A. involve involuntary muscle contraction and relaxation
- B. less than one third of seizures in children caused by epilepsy
- C. febrile seizure usually occur late in the course of high fever
- D. all the above are correct 120
Correct Answer: C
Rationale: A febrile seizure is a convulsion in a young child triggered by a spike in body temperature, often from an infection. Febrile seizures typically occur early in the course of a high fever in children between the ages of 6 months to 5 years old. They are usually brief, lasting for less than five minutes. In about one-third of cases, febrile seizures may occur before the fever is noted by a caregiver. Therefore, the statement that febrile seizures usually occur late in the course of high fever is incorrect.
Nearly all cervical carcinomas contain human papillomavirus (HPV). Which of the following types is never associated with such malignancy?
- A. type6
- B. type 16
- C. type 18
- D. type 31
Correct Answer: A
Rationale: HPV type 6 is typically associated with low-grade lesions and genital warts, not cervical carcinoma.
A client with spinal cord injury at the level of T3 complains of a sudden severe headache and nasal congestion. The nurse observes that the client has a flushed skin with goose bumps. Which of the ff actions should the nurse first take?
- A. Raise the client's head
- B. Place the client on a firm mattress
- C. Call the physician
- D. Administer an analgesic to relieve the pain
Correct Answer: C
Rationale: The sudden severe headache and nasal congestion in a client with a spinal cord injury at the level of T3, along with flushed skin, goose bumps, and potentially increased blood pressure due to autonomic dysreflexia. This is a medical emergency that requires immediate intervention from a healthcare provider. Calling the physician ensures prompt assessment and treatment to prevent further complications associated with autonomic dysreflexia, such as hypertensive crisis, seizures, or stroke. It is important to address this situation promptly to prevent any serious consequences for the client's health.