Nokea
A high school nurse observes a 14-year-old female rubbing her scalp excessively in the gym. What is the most appropriate course of action for the nurse?
- A. Request the female’s parents for a private evaluation of her scalp
- B. Contact the female’s parents regarding the observations
- C. Observe the hairline and scalp for possible signs of lice
- D. Inform the student’s physician about the situation
Correct Answer: C
Rationale: The most appropriate course of action for the nurse is to observe the hairline and scalp for possible signs of lice. The student's behavior of excessively rubbing her scalp raises concerns about a potential infestation, making it necessary to look for signs firsthand. Contacting the parents or the physician should be considered after observing for signs of lice to provide more information and take appropriate action. Requesting a private evaluation from the parents may not be required initially, as lice infestation is a common concern among children and observing for signs is the immediate step to address the situation.
You may also like to solve these questions
The chemotherapeutic agent 5-fluorouracil (5-FU) is ordered for a client as an adjunct measure to surgery. Which statement about chemotherapy is true?
- A. It is a local treatment affecting only tumor cells.
- B. It is a systemic treatment affecting both tumor and normal cells.
- C. It has not yet been proven an effective treatment for cancer.
- D. It is often the drug of choice because it causes few, if any, side effects.
Correct Answer: B
Rationale: The correct answer is that chemotherapy is a systemic treatment affecting both tumor and normal cells. 5-FU, as an antimetabolic drug, inhibits DNA synthesis and interferes with cell replication systemically. It affects all rapidly growing cells, including malignant and normal ones. This drug is used as adjuvant therapy for various cancers. Choice A is incorrect because chemotherapy affects both tumor and normal cells, not just tumor cells. Choice C is incorrect as chemotherapy has been proven effective in treating cancer. Choice D is incorrect because chemotherapy often causes side effects like bone marrow depression, anorexia, stomatitis, nausea, and vomiting.
The nurse is caring for a client receiving warfarin therapy (Coumadin®) following a stroke. The client's PT/INR was completed at 7:00 A.M. prior to the morning meal with an INR reading of 4.0. Which of the following is the nurse's first priority?
- A. Call the physician to request an increase in the Coumadin® dose.
- B. Administer a vitamin K injection IM and notify the physician of the results.
- C. Assess the client for bleeding around the gums or in the stool and notify the physician of the lab results and latest dose of Coumadin®.
- D. Notify the next shift to hold the daily dose of Coumadin® scheduled for 5:00 P.M.
Correct Answer: B
Rationale: In a client receiving warfarin therapy with a high INR of 4.0, the nurse's first priority is to administer a vitamin K injection intramuscularly (IM) and notify the physician of the results. An INR of 4.0 indicates excessive anticoagulation, putting the client at risk of bleeding. Vitamin K is the antidote for warfarin overdose and helps to reverse its effects. It is crucial to administer vitamin K promptly to prevent bleeding complications. Calling the physician to request an increase in the Coumadin® dose is inappropriate and dangerous in this situation, as it would further raise the INR. Assessing the client for bleeding and notifying the physician is important but not the first priority when faced with a critically high INR. Holding the daily dose of Coumadin® may be necessary after administering vitamin K, but it is not the primary action needed to address the acute high INR level.
Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?
- A. The clothing may be potential evidence with legal implications.
- B. Such care facilitates the preservation of potential evidence.
- C. The clothing of a trauma victim can be used for further investigation.
- D. Such care maintains the integrity of the clothing for forensic analysis.
Correct Answer: C
Rationale: In cases of trauma, the clothing of a client can hold crucial evidence that may have legal implications. It is essential for the nurse to avoid cutting through or disrupting any tears, holes, bloodstains, or dirt present on the clothing to preserve this potential evidence. The correct answer highlights the legal importance of preserving the clothing for potential legal implications. Choice B is related but does not emphasize the legal aspect explicitly. Choice C is vague in mentioning further investigation without specifying the legal significance. Choice D focuses more on forensic analysis rather than the legal implications of preserving the clothing.
What are the side effects of first-generation over-the-counter (OTC) antihistamines like diphenhydramine (Benadryl) and hydroxyzine (Atarax) in infants and children?
- A. Reye's syndrome.
- B. cholinergic effects.
- C. paradoxical CNS stimulation.
- D. nausea and diarrhea.
Correct Answer: C
Rationale: The correct answer is paradoxical CNS stimulation. First-generation OTC antihistamines, such as diphenhydramine and hydroxyzine, can lead to paradoxical CNS stimulation in infants and children. This phenomenon is characterized by symptoms like excitement, euphoria, restlessness, and confusion, rather than the expected sedative effect. Due to this unexpected response, these antihistamines are used less frequently in pediatric populations. Reye's syndrome is a rare systemic response to a virus and is not a side effect of antihistamines. First-generation OTC antihistamines do not typically exhibit cholinergic effects. Nausea and diarrhea are uncommon side effects of these antihistamines and are less commonly observed than paradoxical CNS stimulation.
When teaching about preventable diseases, the importance of getting the following vaccines should be emphasized:
- A. human papillomavirus, genital herpes, measles.
- B. pneumonia, HIV, mumps.
- C. syphilis, gonorrhea, pneumonia.
- D. polio, pertussis, measles
Correct Answer: D
Rationale: Vaccines are crucial in preventing communicable diseases. Smallpox has been eradicated globally, so its vaccine is no longer used. Polio, pertussis, and measles are diseases that are controlled by routine childhood immunization. While smallpox has been eradicated, these diseases still exist, making it essential for children to be vaccinated against them. Choices A, B, and C include diseases that are not prevented by vaccination or are not related to routine immunizations, making them incorrect choices.