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Which discharge instruction for a child with encopresis should the nurse question?
- A. Limit milk intake.
- B. Obtain a complete dietary log.
- C. Follow up with a child psychologist.
- D. Offer a diet high in protein.
Correct Answer: D
Rationale: A high-protein diet can worsen constipation; a high-fiber, balanced diet is preferable.
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The best way to tell whether or not a patient is breathing, is for the nurse to watch the movement of the:
- A. Extremities
- B. Head
- C. Eyeball
- D. Chest and nostrils A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET L
Correct Answer: D
Rationale: The best way to assess whether a patient is breathing is to observe the movement of the chest and nostrils. Chest movement indicates inhalation and exhalation, while the nostrils may flare during breathing. Observing these two areas provides a more direct and accurate assessment of breathing compared to extremities, head, or eyeball movements. By focusing on the chest and nostrils, a nurse can quickly and effectively determine if a patient is breathing adequately.
Blood cells are formed in the:
- A. Arterioles
- B. Lymphoid tissue
- C. Bone marrow
- D. Muscle tissue
Correct Answer: C
Rationale: Blood cells are formed in the bone marrow, which is a soft tissue found in the center of most bones in the body. The process of blood cell formation is known as hematopoiesis. Bone marrow contains stem cells that can develop into different types of blood cells, including red blood cells, white blood cells, and platelets. These blood cells play essential roles in carrying oxygen, fighting infections, and assisting in blood clotting. While the other choices listed (arterioles, lymphoid tissue, and muscle tissue) have important functions in the body, blood cell formation specifically occurs primarily in the bone marrow.
Mrs. Diwa has been diagnosed with systemic lupus erythematosus, the nurse upon assessment can expect to find which of the following?
- A. dysphagia
- B. dryness or itching of genitalia
- C. decreased visual acuity or blindness
- D. abnormal lung sounds
Correct Answer: D
Rationale: Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect multiple organs in the body, including the lungs. Patients with SLE are at risk for developing various respiratory complications, which can result in abnormal lung sounds on auscultation. Common respiratory manifestations of SLE include pleurisy, pleural effusion, interstitial lung disease, and pulmonary hypertension. Therefore, the nurse assessing Mrs. Diwa can expect to find abnormal lung sounds indicative of these respiratory complications. However, it is important to note that SLE can also present with a wide range of other symptoms affecting different organ systems.
The nurse is caring for an adolescent who has just started dialysis. The child seems always angry, hostile, or depressed. To what are these behaviors most likely related?
- A. Neurologic manifestations that occur with dialysis
- B. Physiologic manifestations of renal disease
- C. Adolescents having few coping mechanisms
- D. Adolescents often resenting the control and enforced dependence imposed by dialysis
Correct Answer: D
Rationale: Adolescents often resent the control and enforced dependence imposed by dialysis. Adolescence is a challenging time marked by striving for independence and autonomy. When adolescents have to rely on medical interventions like dialysis that impose control and dependence, it can lead to feelings of anger, hostility, and depression. This is a normal psychological response to feeling restricted and not in control of their own lives. It is important for healthcare providers to recognize these emotions and provide support and coping strategies to help the adolescent adjust to the situation.
The nurse has a 2-year-old boy sit in "tailor" position during palpation for the testes. What is the rationale for this position?
- A. It prevents cremasteric reflex.
- B. Undescended testes can be palpated.
- C. This tests the child for an inguinal hernia.
- D. The child does not yet have a need for privacy.
Correct Answer: A
Rationale: The "tailor" position, also known as the frog-leg position, is used during palpation for the testes in young boys because it helps prevent the cremasteric reflex. The cremasteric reflex is a normal reflex in which the testes are pulled upwards towards the inguinal canal when the inner thigh is stroked. By having the child sit in the tailor position, with the knees pulled up and legs rotated outwards, the reflex is less likely to be elicited, allowing for a more accurate examination of the testes.