Nokea
Which assessment would lead the nurse to suspect that a newborn infant has a ventricular septal defect?
- A. A loud, harsh murmur with a systolic thrill
- B. Cyanosis when crying
- C. Blood pressure higher in the arms than in the legs
- D. A machinery-like murmur
Correct Answer: A
Rationale: A loud, harsh murmur combined with a systolic thrill is characteristic of a ventricular septal defect.
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The nurse is caring for a child with Kawasaki disease. A student nurse who is on the unit asks if there are medications to treat the disease. The nurse’s best response to the student nurse is:
- A. Immunogloulin G and ACE inhibitors
- B. Immunoglobulin and heparin
- C. Immunoglobulin G and aspirin
- D. Immunoglobulin and ibuprofen
Correct Answer: C
Rationale: The standard treatment for Kawasaki disease includes Immunoglobulin G and aspirin to reduce inflammation and prevent coronary artery complications.
What is the priority nursing action for a child who is post-operative following a tonsillectomy?
- A. Provide pain management.
- B. Encourage fluid intake.
- C. Monitor for signs of bleeding.
- D. Educate the child about proper oral hygiene.
Correct Answer: C
Rationale: The priority after a tonsillectomy is to monitor for bleeding, as this can be a serious complication.
Patrick, a healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client’s fluid intake because fluid overload may cause:
- A. Cerebral edema
- B. Dehydration
- C. Heart failure
- D. Hypovolemic shock
Correct Answer: A
Rationale: Fluid overload in a patient with meningitis can exacerbate cerebral edema, increasing intracranial pressure and worsening the condition.
The following are features of encephalitis:
- A. Herpes simplex encephalitis has a reasonably good prognosis
- B. Varicella zoster virus encephalitis is predominantly 'cerebellar'
- C. Mumps encephalitis can cause unilateral nerve deafness
- D. Herpes simplex encephalitis predominantly affects the temporal lobe
Correct Answer: D
Rationale: Herpes simplex encephalitis primarily affects the temporal lobe. Prognosis is poor, and varicella zoster encephalitis is not predominantly cerebellar. Mumps encephalitis can cause deafness.
In protein energy malnutrition:
- A. Albumin is typically low
- B. RT3 levels are decreased
- C. There is increased reaction to tuberculin testing
- D. Fatty liver is a recognised finding
Correct Answer: A
Rationale: In protein energy malnutrition, albumin levels typically drop due to a lack of protein intake, leading to hypoalbuminemia and edema.