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When caring for a 3 year old with tetralogy of Fallot, he nurse expects to see fatigue and poor activity tolerance. This is caused by:
- A. Poor muscle tone
- B. Inadequate oxygenation of tissues.
- C. Restricted blood flow leaving the heart
- D. Inadequate intake of food.
Correct Answer: B
Rationale: Tetralogy of Fallot is a heart defect that involves four specific abnormalities in the heart's structure. One of these abnormalities is a ventricular septal defect, which results in a mixing of oxygenated and deoxygenated blood. This leads to inadequate oxygenation of tissues because some of the blood that is pumped out to the body is not fully oxygenated. As a result, the child may experience fatigue and poor activity tolerance due to the reduced oxygen supply to the tissues and organs. This is why the nurse would expect to see these symptoms in a 3-year-old with tetralogy of Fallot.
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What is the purpose of pursed lip breathing?
- A. Helps exhale less volume of air during expiration
- B. Increases expiration
- C. Promotes effective use of the diaphragm
- D. Relieves compensatory burden on upper thorax
Correct Answer: A
Rationale: Pursed lip breathing is a breathing technique commonly used to help improve breathing efficiency in individuals with respiratory conditions such as chronic obstructive pulmonary disease (COPD). By pursing the lips during exhalation, it creates back pressure that helps to keep the airways open longer. This results in slower and more controlled expiration, allowing the individual to exhale a smaller volume of air while maintaining adequate oxygen exchange. This can reduce the feeling of dyspnea (difficulty breathing) and help improve oxygen saturation levels in the blood.
A client has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, the client asks what dysplasia means. Which definition should the nurse provide?
- A. Presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin
- B. Increase in the number of normal cells in a normal arrangement in a tissue or an organ
- C. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found
- D. Alteration in the size, shape, and organization of differentiated cells
Correct Answer: D
Rationale: Dysplasia refers to an alteration in the size, shape, and organization of differentiated cells. It indicates abnormal changes in the cells that can be a precursor to cancer. In the context of a Papanicolaou test, the presence of dysplasia may suggest abnormal cell growth in the cervix, which can potentially develop into cervical cancer if left untreated. It is important for the client to follow up with healthcare providers for further evaluation and management if dysplasia is detected.
. A client is prescribed prednisone (Deltasone) daily. Which statement best explains why the nurse should instruct the client to take this drug in the morning?
- A. Taking the drug at the same time every day establishes a regular routine, reducing the risk of forgetting a dose.
- B. Prednisone has a longer half-life with morning administration, making it more effective.
- C. Morning administration of prednisone mimics the body's natural corticosteroid secretion pattern.
- D. Prednisone is best absorbed when taken on an empty stomach first thing in the morning.
Correct Answer: C
Rationale: The best statement explaining why the nurse should instruct the client to take prednisone (Deltasone) in the morning is that morning administration mimics the body's natural corticosteroid secretion pattern. Cortisol, a natural corticosteroid, is highest in the morning and decreases throughout the day. By taking prednisone in the morning, the client aligns the medication's peak effects with the body's natural cortisol levels, which can help reduce the risk of disrupting the body's internal rhythm and minimize potential side effects. This timing also helps achieve optimal therapeutic effects while minimizing the risk of adrenal suppression and other adverse effects associated with corticosteroid use.
A patient teaching plan should include which of the ff. lifestyle modifications to help control hypertension?
- A. Regular aerobic exercise
- B. Three alcoholic beverages per day
- C. Low-tar cigarettes
- D. Daily multivitamin supplements
Correct Answer: A
Rationale: Regular aerobic exercise is an essential lifestyle modification to help control hypertension. Exercise can help lower blood pressure, improve cardiovascular health, and reduce the risk of developing hypertension. Physical activity strengthens the heart, making it more efficient in pumping blood, which can lead to lower blood pressure levels. Additionally, exercise helps in weight management, which is crucial in controlling hypertension as obesity is a significant risk factor for high blood pressure. Overall, incorporating regular aerobic exercise into a patient's routine can significantly contribute to better blood pressure control and overall health.
After receiving an immunization for pediatric diphtheria, tetanus, and acellular pertussis (DTaP), a patient develops swelling and tenderness at the injection site, a low-grade fever, and malaise. The pediatric nurse informs the patient's parents that:
- A. they should delay future immunizations until the patient sees an allergist.
- B. this is a mild reaction, and teaches them how to manage it.
- C. this is an appropriate reaction, and instructs them to do nothing.
- D. none of the above.
Correct Answer: B
Rationale: Mild reactions like swelling, tenderness, low-grade fever, and malaise are common after DTaP vaccination and can be managed with supportive care.