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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Of the following, the MOST common clinical sign of coarctation of the aorta in older children is
- A. cardiac enlargement
- B. notching of the inferior border of the ribs
- C. a systolic ejection click or thrill in the suprasternal notch
- D. differential blood pressure: arms > legs
Correct Answer: B
Rationale: Notching of the ribs due to collateral circulation is a classic sign of coarctation of the aorta.
A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. What action should the nurse take first?
- A. Notify the healthcare provider
- B. Assure the client that such feelings occur with wound infections
- C. Visualize the abdominal incision
- D. Obtain sterile towels soaked in saline
Correct Answer: C
Rationale: Visualizing the incision helps determine if dehiscence or evisceration has occurred, which requires immediate intervention.
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?
- A. Inappropriate laughter
- B. Increasing anxiety
- C. Weakened cough effort
- D. Asymmetrical weakness
Correct Answer: C
Rationale: A weakened cough effort can lead to respiratory complications, which are life-threatening in ALS patients.
Cataracts are recognised in:
- A. Hyperthyroidism
- B. Down syndrome
- C. Graves' disease
- D. PKU
Correct Answer: B
Rationale: Cataracts are a recognized feature in Down syndrome. They are not typically associated with Hyperthyroidism, Graves' disease, or PKU.
Drugs to be avoided in renal failure include:
- A. Allopurinol
- B. Digoxin
- C. Ceftazidime
- D. Acyclovir
Correct Answer: B
Rationale: Digoxin is avoided in renal failure due to its narrow therapeutic index and renal excretion, which can lead to toxicity.