Nokea
Which laboratory finding should the nurse expect to see in a child with acute rheumatic fever?
- A. Thrombocytopenia
- B. Polycythemia
- C. Decreased ESR
- D. Positive ASO titer
Correct Answer: D
Rationale: The correct answer is D: Positive ASO titer. A positive ASO titer indicates recent streptococcal infection, which is associated with acute rheumatic fever. Thrombocytopenia (choice A) is not a typical laboratory finding in acute rheumatic fever. Polycythemia (choice B) refers to an increased red blood cell count, which is not typically seen in acute rheumatic fever. Decreased ESR (choice C) is not a common laboratory finding in acute rheumatic fever; in fact, ESR is often elevated in inflammatory conditions like rheumatic fever.
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A female client with borderline personality disorder is being discharged today. During morning rounds, the client complains about the aloofness of the night shift nurse and expresses joy to see the nurse on duty. Which response is best for the nurse to provide to this client's dichotomous tendency?
- A. I am glad you like me. Which nurse was acting aloof to you?
- B. Tomorrow I will talk to that nurse about how you were treated last night.
- C. What did the night nurse do that makes you think she is aloof?
- D. I am happy that you are getting better and will be able to go home.
Correct Answer: A
Rationale: Choice A is the best response as it acknowledges the client's feelings while exploring their concerns. By asking which nurse was acting aloof, the nurse shows understanding and allows the client to express their feelings further. This response validates the client's emotions and fosters a therapeutic relationship. Choice B focuses on a future action without addressing the immediate concern at hand. Choice C seeks clarification on the night nurse's behavior, which is a good approach but lacks the personal touch of Choice A. Choice D shifts the focus away from the client's current feelings and concerns, missing the opportunity to address the dichotomous thinking displayed by the client.
A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement?
- A. Replace the IV site with a smaller gauge.
- B. Redress the abdominal incision.
- C. Leave the lights on in the room at night.
- D. Apply soft bilateral wrist restraints.
Correct Answer: C
Rationale: The correct intervention for a client with dementia who is becoming increasingly confused at night and interfering with dressings and IV lines is to leave the lights on in the room at night. This intervention can help reduce confusion and disorientation. Choice A is incorrect because changing the IV site gauge is not the priority in this situation. Choice B is not necessary unless there are signs of infection or other complications at the abdominal incision site, which are not mentioned in the scenario. Choice D should be avoided as using restraints should be a last resort and is not indicated in this case.
A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?
- A. Pain scale rating of 9 on a 0-10 scale
- B. Last menstrual period was 7 weeks ago
- C. Reports white curdy vaginal discharge
- D. History of irritable bowel syndrome (IBS)
Correct Answer: B
Rationale: The correct answer is B. A missed menstrual period could indicate a possible pregnancy-related issue, requiring urgent evaluation. Assessing the menstrual history in a female of reproductive age takes precedence in this scenario. Choice A, the pain scale rating, is important but not as urgent as evaluating the menstrual history. Choice C, reporting white curdy vaginal discharge, may suggest a vaginal infection but is not as critical as ruling out a potential pregnancy. Choice D, the history of irritable bowel syndrome, is relevant but not as crucial as determining pregnancy-related issues in this context.
The mother of a school-age child calls the school to ask when her daughter can return to school after treatment for Pediculosis capitis. What is the nurse's best response?
- A. When all live lice are eliminated by the treatment
- B. Two weeks after the last treatment
- C. As soon as the itching stops
- D. After the treatment kills all the live lice
Correct Answer: D
Rationale: The correct answer is 'After the treatment kills all the live lice.' The child can return to school once all live lice are eliminated to prevent the spread of Pediculosis capitis. This is essential as live lice are highly contagious. Choices A, B, and C are incorrect. Waiting for the itching to stop or for an epidemic to subside does not ensure that all live lice are eradicated, which is crucial to prevent reinfestation and transmission.
While assessing an older client's fall risk, the client tells the nurse that they live at home alone and have never fallen. What action should the nurse take?
- A. Place the client on a high fall risk protocol solely based on their age
- B. Continue to obtain the client data needed to complete the fall risk survey
- C. Inform the client about falls occurring more often at the hospital than at home
- D. Record a minimal risk for falls based on the client's statement alone
Correct Answer: B
Rationale: The correct action for the nurse in this scenario is to continue obtaining client data to complete the fall risk survey. This approach will help in conducting a comprehensive assessment of the client's risk factors. Placing the client on a high fall risk protocol solely based on age without a thorough assessment is premature and can lead to unnecessary interventions. Informing the client about falls in the hospital does not address the client's individual risk factors and is not relevant to the current assessment. Recording a minimal risk for falls based only on the client's statement may overlook other potential risk factors that need to be evaluated.