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: Confusion and somnolence are beginning signs of decompensated shock. Thirst, irritability, and apprehension are signs of compensated shock.
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Clinical manifestations of hypoplastic left-heart syndrome in the 1st 48 hr of life include
- A. always obvious color
- B. deep-blue skin
- C. bounding peripheral pulses
- D. occasional association with Turner syndrome
Correct Answer: C
Rationale: Bounding peripheral pulses are not typical in hypoplastic left-heart syndrome.
Severe hypothermia in newborn is defined as temperature below
- A. 28° C
- B. 30° C
- C. 32° C
- D. 34° C
Correct Answer: A
Rationale: Severe hypothermia in newborns is defined as a core body temperature below 28° C, which is life-threatening and requires immediate intervention.
Rare causes of bloody diarrhoea include:
- A. Campylobacter infection
- B. Peutz-Jegher's syndrome
- C. Enterotoxigenic E. coli
- D. Crohn's disease
Correct Answer: B
Rationale: Rare causes of bloody diarrhoea include conditions like Peutz-Jegher's syndrome which is a genetic disorder causing polyps in the gastrointestinal tract. Campylobacter Shigella and Enterotoxigenic E. coli are common causes of infectious diarrhoea while Crohn's disease is a chronic inflammatory condition.
A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. The client is intubated and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain?
- A. Breath sounds over bilateral lung fields.
- B. Carotid pulsation during compressions
- C. Deep tendon reflexes
- D. Core body temperature
Correct Answer: A
Rationale: Assessing breath sounds ensures that the endotracheal tube is properly placed and that ventilation is effective, which is critical in a cardiac arrest situation.
A cardiac catheterization of a client with heart disease indicates the following blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and ? % proximal right coronary artery (RCA). The client later asks the nurse 'what does all this mean for me?' What information should the nurse provide?
- A. Blood supply to the heart is diminished by atherosclerotic lesions, which necessitate lifestyle changes.
- B. Blood vessels supplying the pumping chamber have blockages indicating a past heart attack.
- C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting through to the heart muscle.
- D. The heart is not receiving enough blood, so there is a risk of heart failure and fluid retention.
Correct Answer: C
Rationale: This explanation provides a clear understanding of the severity of the blockages and the implications for the client's heart function.