Nokea
Which is an important nursing consideration when chest tubes will be removed from a child?
- A. Explain that it is not painful.
- B. Explain that only a Band-Aid will be needed.
- C. Administer analgesics before the procedure.
- D. Expect bright red drainage for several hours after removal.
Correct Answer: C
Rationale: Administering analgesics before removing chest tubes from a child is an important nursing consideration because the procedure may cause pain or discomfort. While it is ideal to minimize pain during and after the removal, it is essential to anticipate the possibility of discomfort and provide appropriate pain management to ensure the child's comfort and well-being. By administering analgesics before the procedure, nurses can help alleviate any potential pain and promote a more positive experience for the child.
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The home health nurse asks a child's mother many questions as part of the assessment. The mother answers many questions, then stops and says, "I don't know why you ask me all this. Who gets to know this information?" The nurse should take which action?
- A. Determine why the mother is so suspicious.
- B. Determine what the mother does not want to tell.
- C. Explain who will have access to the information.
- D. Explain that everything is confidential and that no one else will know what is said.
Correct Answer: C
Rationale: The correct action for the nurse to take in this situation is to explain who will have access to the information. This can help build trust with the child's mother and alleviate any concerns she may have about the confidentiality of the information shared during the assessment. By explaining clearly who will have access to the information and how it will be used, the nurse can address the mother's concerns and ensure that she feels comfortable sharing necessary information for the child's care. This open communication is essential in building a supportive and trusting relationship between the nurse and the child's mother.
Which of the following conditions is suspected?
- A. Anemia
- B. Rheumatic arthritis
- C. Leukemia
- D. Systematic Lupus Erythematosus (SLE)
Correct Answer: C
Rationale: Leukemia is a type of cancer that affects the blood and bone marrow, leading to an overproduction of abnormal white blood cells. The symptoms of leukemia can include fatigue, weakness, weight loss, frequent infections, fever, bruising or bleeding easily, and bone pain. Given the vague presenting symptoms and the potential involvement of multiple bodily systems, leukemia is a condition that should be suspected and investigated further. Anemia, rheumatic arthritis, and systematic lupus erythematosus can also present with some similar symptoms, but for the given scenario, leukemia is the most probable condition to suspect.
What should the client at risk for developing AIDS be advised to do?
- A. Abstain from anal intercourse
- B. Have a semen analysis done
- C. Have an ELISA test for antibodies
- D. Inform all sexual contacts
Correct Answer: C
Rationale: The client at risk for developing AIDS, which is caused by the Human Immunodeficiency Virus (HIV), should be advised to have an ELISA test for antibodies to check for the presence of the virus. ELISA is a standard blood test used for HIV screening because it can detect antibodies produced by the body in response to HIV infection. Early detection through testing is crucial to initiate treatment interventions and prevent further transmission of the virus. It is important for the client to undergo this test to determine their HIV status and receive appropriate medical care and support.
In fetal period, all are true EXCEPT
- A. 10 weeks - midgut returns to abdomen
- B. 12 weeks - external genitalia formed
- C. 24 weeks - surfactant production begun
- D. 26 weeks - face clearly recognizable
Correct Answer: D
Rationale: Face recognition typically occurs earlier than 26 weeks.
The client with epilepsy is taking the prescribed dose of phenytoin (Dilantin) to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/ml. Which of the following symptoms would be expected as a result of this laboratory result?
- A. Nystagmus
- B. No symptoms, because this is normal
- C. Tachycardia therapeutic level
- D. Slurred speech
Correct Answer: A
Rationale: A phenytoin blood level of 35 mcg/ml is considered to be above the therapeutic range (usually 10-20 mcg/ml for phenytoin). At this elevated level, the client is at risk for phenytoin toxicity. Symptoms of phenytoin toxicity include nystagmus (rapid, involuntary eye movements), as well as other symptoms such as confusion, slurred speech, ataxia, and tremors. Tachycardia is not typically associated with phenytoin toxicity. Therefore, the expected symptom in this case would be nystagmus.