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When caring for a patient with Syndrome of inappropriate Antidiuretic Hormone Secretion (SIADH), the nurse would expect her patient to exhibit the following clinical signs and symptoms (Select all that apply):
- A. Fluid retention
- B. Hypotonicity
- C. Anorexia
- D. Frequent urination
Correct Answer: A,B,C
Rationale: Step-by-step rationale:
A: Fluid retention - In SIADH, there is excessive ADH secretion leading to water retention and dilutional hyponatremia.
B: Hypotonicity - Due to water retention, serum osmolality decreases leading to hypotonicity.
C: Anorexia - SIADH can cause nausea, vomiting, and anorexia due to hyponatremia and cerebral edema.
Incorrect choices:
D: Frequent urination - SIADH causes water retention, leading to decreased urine output, not frequent urination.
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A nurse is performing education for the guardians of an HIV positive teen. Which statement indicates the need for further teaching?
- A. It is important for her to have normal growth and development.
- B. Adherence to antiretroviral therapy is needed.
- C. We will need to inform the school about her infection.
- D. She should get her annual flu shot at the doctor's office.
Correct Answer: C
Rationale: The correct answer is C. It is not necessary to inform the school about the teen's HIV infection due to confidentiality laws protecting the teen's privacy. Revealing this information could lead to stigma and discrimination. The other statements are all important for the teen's health and well-being. A: Normal growth and development are crucial for overall health. B: Adherence to antiretroviral therapy is necessary to manage the HIV infection. D: Annual flu shots are recommended to prevent complications.
A complication of hemophilia is:
- A. Mucositis
- B. Hemoarthritis
- C. Thrombocytopenia
- D. Acute Chest Syndrome
Correct Answer: B
Rationale: The correct answer is B: Hemoarthritis. Hemophilia is a bleeding disorder where blood does not clot properly. Hemoarthritis is a common complication, characterized by bleeding into joints leading to pain, swelling, and limited range of motion. Mucositis (A) is inflammation of mucous membranes, not specific to hemophilia. Thrombocytopenia (C) is a low platelet count, not directly related to hemophilia. Acute Chest Syndrome (D) is a complication of sickle cell disease, not hemophilia.
The nurse is caring for a child with frostbite would expect the patient to display:
- A. Redness and swelling of the hands
- B. Blisters that appear 24 to 48 hours after rewarming
- C. Itching and burning that persists after rewarming
- D. Fever
Correct Answer: B
Rationale: The correct answer is B because blisters appearing 24 to 48 hours after rewarming is a common symptom of frostbite. This occurs due to damage to the blood vessels and tissues. A: Redness and swelling are more indicative of mild frostbite. C: Itching and burning are not typical symptoms of frostbite. D: Fever is not a common symptom of frostbite.
Fentanyl 30mcg IV is ordered. The vial contains 0.05mg/ml. How many ml should the nurse administer?
- A. 0.3 ml
- B. 3 ml
- C. 0.06 ml
- D. 0.6 ml
Correct Answer: D
Rationale: To calculate the amount of Fentanyl to administer, first convert 30mcg to mg by dividing by 1000 (30mcg = 0.03mg). Then, divide the dose by the concentration of the vial (0.03mg ÷ 0.05mg/ml = 0.6ml). The correct answer is D (0.6ml). Choice A (0.3ml) is incorrect because it doesn't account for the correct dosage calculation. Choice B (3ml) is incorrect as it is too high, leading to potential overdose. Choice C (0.06ml) is incorrect as it miscalculates the dosage based on the vial concentration.
Which should be the major consideration in selecting toys for a child who is cognitively impaired?
- A. Age appropriateness
- B. Ability to teach useful skills
- C. Safety
- D. Ability to provide exercise
Correct Answer: C
Rationale: The major consideration in selecting toys for a cognitively impaired child should be safety (Choice C). Safety is crucial as children with cognitive impairments may have difficulty understanding potential dangers or using toys appropriately. Age appropriateness (Choice A) is important, but safety should take precedence. Teaching useful skills (Choice B) can be beneficial but may not be the primary focus. Providing exercise (Choice D) is valuable, but ensuring safety should come first.