Nokea
What should the nurse caring for a 6-year-old child with acute glomerulonephritis anticipate as the most challenging aspect of care to implement?
- A. Forced fluids
- B. Increased feedings
- C. Bed rest
- D. Frequent position changes
Correct Answer: C
Rationale: The correct answer is C: Bed rest. During the acute phase of glomerulonephritis, bed rest is usually recommended. A diet of restricted fluid, sodium, potassium, and phosphate is initially required. Bed rest can be very challenging to implement with an active 6-year-old child. Forced fluids (choice A) may be necessary to maintain hydration. Increased feedings (choice B) may not be as difficult to implement as bed rest. Frequent position changes (choice D) may also be important but are not typically the most challenging aspect of care for a child with acute glomerulonephritis.
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Based on the interpretation of this strip, what action should be implemented first?
- A. Call a code.
- B. Start CPR.
- C. Administer IV fluids.
- D. Apply oxygen.
Correct Answer: A
Rationale: The correct answer is A: 'Call a code.' In the context of ventricular fibrillation (V-Fib), immediate defibrillation is crucial. Calling a code is the first step to activating the emergency response team, including individuals trained to provide defibrillation. Starting CPR (Choice B) may be necessary but should follow defibrillation. Administering IV fluids (Choice C) and applying oxygen (Choice D) are important interventions in cardiac arrest cases, but in V-Fib, the priority is defibrillation to restore normal heart rhythm.
A client with a spinal cord injury at the level of T1 is at risk for autonomic dysreflexia. Which symptom is indicative of this condition?
- A. Hypotension
- B. Tachycardia
- C. Severe headache
- D. Flushed skin below the level of injury
Correct Answer: C
Rationale: Corrected Rationale: Autonomic dysreflexia is a condition commonly seen in clients with spinal cord injuries at T6 or above. It is characterized by a sudden onset of severe hypertension, pounding headache, profuse sweating, nasal congestion, and flushing of the skin above the level of injury. The severe headache is a key symptom resulting from uncontrolled hypertension. Choices A, B, and D are incorrect as autonomic dysreflexia typically presents with hypertension, not hypotension, tachycardia, or flushed skin below the level of injury.
A client with a history of hypertension is admitted with a blood pressure of 220/120 mm Hg. What is the priority nursing action?
- A. Administer antihypertensive medication as prescribed.
- B. Place the client in a supine position.
- C. Obtain a detailed health history.
- D. Monitor urine output.
Correct Answer: A
Rationale: Administering antihypertensive medication is the priority nursing action in this situation. The extremely high blood pressure of 220/120 mm Hg puts the client at risk of severe complications such as stroke, heart attack, or kidney damage. Lowering the blood pressure promptly is crucial to prevent these complications. Placing the client in a supine position or obtaining a detailed health history are not immediate actions needed to address the hypertensive crisis. Monitoring urine output, although important, is not the priority when the client's blood pressure is critically high.
Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI), a client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia. Which finding should the nurse document in the EMR as a therapeutic response to the lidocaine infusion?
- A. Stabilization of BP ranges
- B. Cessation of chest pain
- C. Reduced heart rate
- D. Decreased frequency of episodes of VT
Correct Answer: D
Rationale: The correct answer is D. Decreased frequency of ventricular tachycardia (VT) episodes indicates that the lidocaine infusion is effectively managing the ventricular tachycardia. Stabilization of BP ranges (choice A) may not directly correlate with the therapeutic response to lidocaine for VT. Cessation of chest pain (choice B) may indicate pain relief but does not specifically address the effectiveness of lidocaine for VT. Reduced heart rate (choice C) is not a direct indicator of the response to lidocaine for managing VT.
Which type of lipoprotein is associated with decreasing the risk of atherosclerosis?
- A. High-density lipoprotein (HDL)
- B. Low-density lipoprotein (LDL)
- C. Very low-density lipoprotein (VLDL)
- D. Intermediate-density lipoprotein (IDL)
Correct Answer: A
Rationale: The correct answer is High-density lipoprotein (HDL). HDL is known as 'good' cholesterol because it helps remove cholesterol from the arteries, reducing the risk of atherosclerosis. LDL (choice B) is considered 'bad' cholesterol as it can deposit cholesterol in the arteries, increasing the risk of atherosclerosis. VLDL (choice C) and IDL (choice D) are also associated with increased risk of atherosclerosis rather than decreasing it.