Nokea
What does the nurse need to assess first when caring for a child with a suspected myocardial infarction?
- A. Blood pressure and heart rate
- B. Chest pain and anxiety levels
- C. Oxygen saturation and respiratory rate
- D. Electrocardiogram and heart sounds
Correct Answer: D
Rationale: The first priority in a suspected myocardial infarction is to assess the heart's electrical activity using an electrocardiogram and listen to heart sounds for any abnormality such as murmurs.
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An adult female with multiple sclerosis (MS) falls while walking to the bathroom. On transfer to the intensive care unit, she is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?
- A. Determine client's last dose of corticosteroids
- B. Determine neurological baseline prior to the fall
- C. Administer a PRN IV antiemetic as prescribed
- D. Complete head to toe neurological assessment.
Correct Answer: D
Rationale: The symptoms suggest increased intracranial pressure or a neurological emergency. A thorough neurological assessment is necessary to identify the cause and guide further interventions.
A child aged 10 days has ambiguous genitalia:
- A. If a buccal smear is chromatin negative, there is a serious risk of an Addisonian crisis
- B. A raised urinary output of pregnanetriol would confirm a diagnosis of CAR
- C. The finding of the genotype 45 XO would reliably explain the anomaly
- D. If testicles were present in the 'labia', an acceptable explanation would be Klinefelter's syndrome
Correct Answer: B
Rationale: A raised urinary pregnanetriol indicates congenital adrenal hyperplasia (CAR). Chromatin-negative buccal smear suggests male genotype, and 45 XO is Turner syndrome, not related to ambiguous genitalia. Klinefelter's syndrome does not explain testicles in the labia.
Causes of a dilated renal pelvis in a foetal scan include:
- A. Normal variant
- B. Vesico-ureteric reflux
- C. Pelvi-ureteric junction obstruction
- D. Multicystic kidney
Correct Answer: A
Rationale: A dilated renal pelvis can be a normal variant in a foetal scan, often resolving spontaneously without intervention.
Which is the most appropriate nursing action related to the administration of digoxin (Lanoxin) to an infant?
- A. Counting the apical rate for 30 seconds before administering the medication
- B. Withholding a dose if the apical heart rate is less than 100 beats/min
- C. Repeating a dose if the child vomits within 30 minutes of the previous dose
- D. Checking respiratory rate and blood pressure before each dose
Correct Answer: B
Rationale: As a rule, if the pulse rate of an infant is below 100 beats/min, the medication is withheld and the physician is notified.
Management of a patient with an INR of 8.7 from warfarin overdose includes:
- A. Vitamin K
- B. Cryoprecipitate
- C. Fresh frozen plasma
- D. Desmopressin
Correct Answer: A
Rationale: The correct answer is A because vitamin K is the primary treatment for reversing warfarin overdose. The other options (b-e) are less commonly used or not indicated for this situation.