Nokea
When the nurse is educating parents of young kids with congenital heart defects, it is essential to teach them about the early signs and symptoms of heart failure so that they can recognize it sooner. Which of the following should the nurse emphasize as early signs of heart failure?
- A. Diaphoresis
- B. Sudden weight gain
- C. No wet diapers
- D. Hypoxia
- E. Increased appetite
Correct Answer: A, B, C, D
Rationale: Diaphoresis, sudden weight gain, no wet diapers, and hypoxia are early signs of heart failure in children.
You may also like to solve these questions
The nurse is caring for a client seven hours postoperative following a subtotal thyroidectomy. The client reports peripheral numbness and tingling, muscle twitching, and spasms. The nurse anticipates a prescription for
- A. levothyroxine
- B. hydrocortisone
- C. thiamine
- D. calcium gluconate
Correct Answer: D
Rationale: These symptoms suggest hypocalcemia, a common complication post-thyroidectomy due to parathyroid gland disruption. Calcium gluconate is the appropriate treatment.
The nurse is caring for a client who is recovering from surgery. Which assessment data would suggest that the client's pain is not well controlled?
- A. Tachypnea
- B. Bradycardia
- C. Nausea
- D. Mydriasis
- E. Increased blood glucose
Correct Answer: A, C, E
Rationale: Tachypnea, nausea, and increased blood glucose are signs of uncontrolled pain.
The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 3 of 5
Nurses' Notes
1322: 10-year-old client and his parents report an 8-day history of a brownish-raised lesion over the back of his left leg. The parents report that the size of the rash has increased. The parents report returning from a one-week camping trip three weeks ago. The parents deny efficacy with over-the-counter antihistamine creams. The client's parents deny that the child has had a fever but has felt 'warm' occasionally and endorsed an intermittent headache. They report an area of firmness in the child's groin. On assessment, there was an erythematous, raised, nonpainful, oval patch on the back of his left leg. This was an enlargement of an inguinal lymph node. The child is alert and fully oriented and denies any pain. Peripheral pulses palpable 2+. No cyanosis or edema in the extremities. Lung sounds clear bilaterally. The parents report that the child did not receive the seasonal influenza vaccine. He currently takes a multivitamin for iron deficiency anemia and was hospitalized one year ago for an appendectomy. The parents state that the child’s sibling had influenza one month ago. Vital signs: T 98.8°F (37.1°C); HR 78 beats/min; RR 16 breaths/min; BP 110/76 mm Hg. SpO2 97% on room air.
The client is demonstrating manifestations consistent with
- A. influenza
- B. Rocky Mountain spotted fever
- C. Lyme disease
- D. None of the above
Correct Answer: C
Rationale: The bullseye rash, lymphadenopathy, and camping history are consistent with Lyme disease.
The nurse is educating a group of students on the measles, mumps, and rubella (MMR) vaccine. Which statement, if made by the student, would indicate effective teaching?
- A. Egg allergy is a contraindication to giving this vaccine.
- B. This is a three-series vaccine that should be started at birth.
- C. It is safe for breastfeeding women to receive the MMR vaccine.
- D. This vaccine is safe if the client is pregnant.
Correct Answer: C
Rationale: The MMR vaccine is safe for breastfeeding women but contraindicated in pregnancy and not started at birth. Egg allergy is no longer a contraindication.
The following scenario applies to the next 1 items
The case manager is reviewing the medical record of a client with schizophrenia
Item 1 of 1
Progress Notes
Discharge Summary
0900: Third involuntary admission in the past six months. The client was admitted four days ago because of florid psychosis. During the stay, the client was stabilized with their prescribed aripiprazole. Once stabilized, the client reported nonadherence to aripiprazole because they 'forget.' It is documented that the client also missed two follow-up appointments for some unknown reason. The client was prescribed aripiprazole oral disintegrating tablet (ODT) to optimize adherence versus tablets. Provided two refills and a follow-up appointment at discharge. Thorough counseling was provided regarding the dosing schedule. Considering the client's repeated nonadherence, there is a high probability of readmission. Will consult case management for follow-up.
Orders
0815:
• discharge client home
• case management consultation for repeated readmissions
• arrange outpatient follow-up appointment prior to discharge
• give morning dose of aripiprazole prior to discharge
• discharge with a prescription for aripiprazole 15 mg ODT daily
The case manager reviews the physician's progress notes and orders. Select the actions the case manager should take to reduce the client's risk of readmission.
- A. perform a post discharge follow-up phone call
- B. recommend the client be prescribed a long acting injectable antipsychotic
- C. review the client's advanced directives
- D. assess the client's social determinants of health
- E. arrange for more frequent follow-up appointments
Correct Answer: A, B, D, E
Rationale: Follow-up calls, long-acting injectable antipsychotics, assessing social determinants, and frequent appointments address nonadherence and reduce readmission risk.