Nokea
Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock?
- A. Thirst
- B. Irritability
- C. Apprehension
- D. Confusion and somnolence
Correct Answer: D
Rationale: As shock progresses and becomes decompensated in a child, profound perfusion abnormalities lead to inadequate oxygen and nutrient delivery to the brain. This can result in altered mental status such as confusion and somnolence. As the body struggles to maintain adequate perfusion to vital organs, the brain may be one of the first organs to demonstrate signs of inadequate perfusion. Thirst, irritability, and apprehension are more commonly seen in the early stages of shock. Confusion and somnolence indicate a more severe and critical state of shock where the child's body is struggling to maintain adequate blood flow to vital organs, including the brain.
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The lungs regulate acid-base balance b₃y⻠all of the following except:
- A. Excreting HCO into the blood
- B. Controlling carbon dioxide levels
- C. Slowing ventilation
- D. Increasing ventilation
Correct Answer: C
Rationale: The lungs help regulate acid-base balance primarily by controlling carbon dioxide levels through ventilation. When carbon dioxide levels increase in the blood, the lungs increase ventilation to exhale more carbon dioxide and maintain the acid-base balance. Slowing ventilation (Option C) would not help in regulating the acid-base balance as it would lead to a buildup of carbon dioxide in the blood, causing respiratory acidosis. Excreting HCO into the blood (Option A) helps maintain acid-base balance by regulating bicarbonate levels, and increasing ventilation (Option D) is the mechanism through which the lungs primarily adjust acid-base balance.
The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. How should the nurse interpret this finding?
- A. Normal finding
- B. Finding requiring a referral
- C. Abnormal finding
- D. Normal finding, but requires rechecking in 1 month
Correct Answer: A
Rationale: The closure of the anterior fontanel in a 14-month-old infant is a normal finding. The anterior fontanel typically closes by around 18 months of age. The closure of the fontanel is a sign of normal growth and development as the bones of the skull fuse together. It is not a cause for concern at this age, and the nurse should document this as a normal finding.
7-year-old Damon has cystitis; which of the following would Nurse Elena expect when assessing the child?
- A. Dysuria
- B. Costovertebral tenderness
- C. Flank pain
- D. High fever
Correct Answer: A
Rationale: Cystitis is inflammation of the bladder, commonly caused by a bacterial infection. In children, symptoms of cystitis often include dysuria, which is painful or difficult urination. This symptom is frequently observed in children with cystitis. Costovertebral tenderness and flank pain are more indicative of kidney involvement (such as in pyelonephritis) rather than just bladder inflammation like in cystitis. High fever may also be present in severe cases of cystitis, but dysuria is the more specific and common symptom associated with this condition in children.
Which action by the nurse demonstrates use of evidence-based practice (EBP)?
- A. Gathering equipment for a procedure
- B. Documenting changes in a patient's status
- C. Questioning the use of daily central line dressing changes
- D. Clarifying a physician's prescription for morphine
Correct Answer: C
Rationale: Questioning the use of daily central line dressing changes demonstrates the use of evidence-based practice (EBP) by the nurse. In EBP, decisions about patient care should be informed by the best available evidence, clinical expertise, and patient preferences. By questioning the necessity of daily dressing changes for central lines, the nurse is seeking to ensure that the care provided is based on sound evidence and best practices rather than simply following routine procedures. This critical thinking and questioning approach aligns with the principles of evidence-based practice.
A client is scheduled to receive methotrexate (Folex), 0.625 mg/kg P.O. daily, to treat malignant lymphoma. Before administering the drug, the nurse reviews the client's medication history. Which of the following drugs might interact with methotrexate?
- A. digoxin (Lanoxin)
- B. Probenecid (Benemid)
- C. theophylline (Slo-Phyllin)
- D. Famotidine (Pepcid)
Correct Answer: B
Rationale: Probenecid is a drug that can interact with methotrexate by inhibiting its renal tubular secretion, leading to increased methotrexate levels and potential toxicity. It is essential to monitor the client closely for signs of methotrexate toxicity if both drugs are being used concurrently. The other options, digoxin, theophylline, and famotidine, do not have significant interactions with methotrexate that would result in increased toxicity.