Nokea
When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?
- A. Daily weight
- B. Vital signs
- C. Level of consciousness
- D. Bowel sounds
Correct Answer: A
Rationale: Daily weight is crucial in monitoring fluid balance in clients with nephrotic syndrome, as they are prone to edema.
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The school nurse has been following a child who frequently complains of dizziness and headache. Today, she is brought in after fainting in the cafeteria following a nosebleed. Her BP is 122/85, and her radial pulses are bounding. The nurse suspects she has:
- A. Transposition of the great vessels
- B. Coarctation of the aorta (COA)
- C. Aortic stenosis (AS)
- D. Pulmonic stenosis (PS)
Correct Answer: B
Rationale: In older children, COA can cause elevated blood pressure, headache, fainting, and bounding radial pulses.
The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess urine output?
- A. Inserting a foley catheter.
- B. Weighing the diapers.
- C. Comparing intake with output.
- D. Measuring the amount of water added to the formula.
Correct Answer: B
Rationale: Weighing diapers is a non-invasive and accurate method to assess urine output in infants, which is crucial for monitoring the effectiveness of diuretic therapy.
A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression. After another minute of compressions, the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor. At this point, what is the priority intervention for the nurse?
- A. Prepare for transcutaneous pacing
- B. Deliver another defibrillator shock
- C. Administer IV Epinephrine per ACLS protocol
- D. Give IV dose of adenosine rapidly over 1-2 seconds
Correct Answer: D
Rationale: SVT can be treated by rapidly administering adenosine to restore normal sinus rhythm.
A child has been seen by the school nurse for dizziness since the start of the school term. It happens when standing in line for recess and homeroom. The child now reports that she would rather sit and watch her friends play hopscotch because she cannot count out loud and jump at the same time. When the nurse asks her if her chest ever hurts, she says yes. Based on this history, the nurse suspects that she has:
- A. Ventricular septal defect (VSD)
- B. Aortic stenosis (AS)
- C. Mitral valve prolapse
- D. Tricuspid atresia
Correct Answer: B
Rationale: AS can progress and result in exercise intolerance, which may improve with rest.
A seizure episode may be mimicked by:
- A. Breath-holding episode
- B. Choreoathetosis
- C. Hysterical reactions
- D. Vasovagal attack
Correct Answer: A
Rationale: Breath-holding episodes in children can mimic seizures due to transient loss of consciousness, often triggered by emotional stress or pain.