Nokea
Which instruction is essential to give the parents before the child's discharge?
- A. Return the child for a follow-up visit in 3 to 5 days.
- B. Give the child nothing by mouth for the next 12 hours.
- C. Check the child's pupillary response every 4 hours.
- D. Awaken the child every 4 hours during the first night.
Correct Answer: D
Rationale: Awakening the child every 4 hours during the first night allows monitoring for neurological deterioration, such as altered consciousness, critical after a head injury.
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Which of the following is the priority nursing action if the child shows symptoms of hypoglycemic reaction?
- A. Give the child orange juice or milk to drink.
- B. Give the child 10% glucose I.V.
- C. Notify the physician immediately.
- D. Administer a second dose of insulin.
Correct Answer: A
Rationale: For hypoglycemia, the priority is to rapidly raise blood glucose. Giving orange juice or milk provides quick-acting carbohydrates, the first-line treatment for conscious patients with mild to moderate hypoglycemia.
The physician orders I.V. insulin, and the registered nurse (RN) prepares to give it. The licensed practical nurse (LPN) is assisting the RN with the unstable client. Which of the following types of insulin should the LPN anticipate that the physician will order?
- A. Regular insulin (Humulin R)
- B. Isophane insulin suspension (Humulin N)
- C. Insulin aspart (NovoLog)
- D. None of the above
Correct Answer: A
Rationale: Regular insulin (Humulin R) is used for I.V. administration in DKA because it has a rapid onset and can be titrated to manage hyperglycemia effectively. Other insulins, like NPH or aspart, are not suitable for I.V. use.
Which statement by the nurse would best help the parents cope with their feelings?
- A. You'll feel better if you visited your child for shorter periods of time.
- B. Don't worry. You're doing a great job, and everything will work out for the best.
- C. This is painful for you. Let's identify things you can do to help make your child feel good.
- D. It's sad that you feel helpless. What do you usually do to take your mind off your worries?
Correct Answer: C
Rationale: Acknowledging the parents' pain and suggesting actionable ways to help their child empowers them, addressing helplessness constructively and fostering coping.
19 years old primigravida comes in emergency at 32 weeks of gestation. She is complaining of blurring of vision,gross edema. On examination her B.P is 170/115 mm Hg. What is the most likely diagnosis:
- A. Hypertension.
- B. Renal disease.
- C. Eclampsia.
- D. Preeclampsia.
- E. Thyroid disease.
Correct Answer: D
Rationale: Preeclampsia is characterized by hypertension (BP ≥140/90 mmHg) after 20 weeks gestation with symptoms like edema and visual disturbances. Eclampsia involves seizures which are not mentioned. Hypertension alone lacks other symptoms and renal or thyroid disease are less likely without specific indicators.
Which response by the nurse provides the best clarification about the disease process?
- A. If you're afraid of getting HIV, you'll be safer if you avoid having sex with past sex partners.
- B. An HIV-positive individual may not develop symptoms of AIDS for years.
- C. HIV can only be transmitted when symptoms of AIDS are present.
- D. The medication prescribed for AIDS also protects against HIV infection.
Correct Answer: B
Rationale: HIV can be asymptomatic for years, during which it is still transmissible, making this clarification critical for understanding the disease process and transmission risk.