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Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select one that doesn't apply.
- A. Providing a low-fat, well-balanced diet.
- B. Teaching the child effective hand-washing techniques.
- C. Notifying the primary health care provider (PHCP) if jaundice is present.
- D. Instructing the parents to avoid administering medications unless prescribed.
Correct Answer: D
Rationale: The correct answer is instructing the parents to avoid administering medications unless prescribed. This choice is not directly related to the care of a child with hepatitis. It is essential for the nurse to educate the child and family about providing a low-fat, well-balanced diet to support the liver, teaching effective hand-washing techniques to prevent the spread of infection, and notifying the primary health care provider if jaundice is present to monitor the progression of the disease and adjust the treatment plan accordingly. Avoiding unnecessary medications is crucial, but it should be done under healthcare provider guidance, so the statement should be revised to reflect this aspect. Therefore, the other options are appropriate for the care of a child with hepatitis.
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A client with asthma has low-pitched wheezes present on the final half of exhalation. One hour later the client has high-pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
- A. Has increased airway obstruction
- B. Has improved airway obstruction
- C. Needs to be suctioned
- D. Exhibits hyperventilation
Correct Answer: B
Rationale: The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened. With no evidence of secretions, there is no support to indicate the need for suctioning. Wheezes changing from low-pitched to high-pitched and extending throughout exhalation suggest a progression in airway constriction, indicating an increase in airway obstruction. Option B is incorrect because the change in wheezes from low to high pitch does not suggest an improvement in airway obstruction. Option C is incorrect as there is no indication of secretions requiring suctioning. Option D is incorrect as hyperventilation is not typically associated with the described change in wheezes.
A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to
- A. A social worker from the local hospital
- B. An occupational therapist from the community center
- C. A physical therapist from the rehabilitation agency
- D. Another client with diabetes mellitus who takes insulin
Correct Answer: B
Rationale: An occupational therapist from the community center would be the most appropriate referral for this client. Occupational therapists specialize in helping individuals improve fine motor skills, which are essential for tasks like drawing up insulin injections. A social worker typically focuses on psychosocial aspects, a physical therapist on physical mobility, and another client with diabetes would not have the professional expertise to address the client's specific needs related to insulin preparation.
A physician suspects a patient may have pancreatitis. Which of the following tests would be most appropriate to diagnose this condition?
- A. CK and Troponin
- B. BUN and Creatinine
- C. Amylase and Lipase
- D. HDL and LDL Cholesterol Levels
Correct Answer: C
Rationale: To diagnose pancreatitis, testing amylase and lipase levels is crucial. Amylase and lipase are enzymes produced by the pancreas that help digest carbohydrates and lipids. In pancreatitis, these enzymes are released in high amounts into the bloodstream due to pancreatic inflammation or damage. Elevated levels of amylase and lipase in blood tests strongly indicate pancreatitis. Choice A, CK and Troponin, are cardiac markers used in diagnosing heart conditions like myocardial infarction, not pancreatitis. Choice B, BUN and Creatinine, are kidney function tests, not specific to pancreatitis. Choice D, HDL and LDL Cholesterol Levels, are lipid profile tests used to assess cardiovascular health, not for diagnosing pancreatitis.
The nurse is caring for a patient who has recently had a successful catheter ablation. Which assessment finding demonstrates a successful outcome of this procedure?
- A. The patient is free of electrolyte imbalances
- B. The patient's WBC count is within normal limits
- C. The patient's EKG reading is regular
- D. The patient's urine output is 45 mL/hour
Correct Answer: C
Rationale: A successful outcome of a catheter ablation procedure for arrhythmias, particularly SVT, is indicated by a regular EKG reading. Catheter ablation involves the use of radiofrequency energy to destroy the conduction fiber in the heart responsible for the arrhythmia. This destruction helps in preventing further episodes of arrhythmia. While choices A, B, and D are important assessments in patient care, they are not specific indicators of the success of a catheter ablation procedure. Electrolyte imbalances, WBC count, and urine output can be affected by various factors and are not directly related to the effectiveness of a catheter ablation in treating arrhythmias.
The nurse is caring for a 2-year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?
- A. Neurotoxicity
- B. Hepatomegaly
- C. Nephrotoxicity
- D. Ototoxicity
Correct Answer: C
Rationale: The correct answer is nephrotoxicity. Calcium disodium edetate, used in chelation therapy for lead poisoning, can lead to kidney toxicity. This is an important side effect to monitor in patients undergoing this treatment. Choices A, B, and D are incorrect. Neurotoxicity, hepatomegaly, and ototoxicity are not typically associated with calcium disodium edetate therapy for lead poisoning.