Nokea
Which nursing consideration is important when caring for a child with impetigo contagiosa?
- A. Apply topical corticosteroids to decrease inflammation.
- B. Carefully remove dressings so as not to dislodge undermined skin, crusts, and debris.
- C. Carefully wash hands and maintain cleanliness when caring for an infected child.
- D. Examine child under a Wood lamp for possible spread of lesions.
Correct Answer: C
Rationale: Carefully washing hands and maintaining cleanliness when caring for an infected child with impetigo contagiosa is important due to its highly contagious nature. Impetigo is a skin infection that is easily spread through direct contact with the lesions or with items contaminated by the infected person such as towels, clothing, or bedding. By washing hands and maintaining cleanliness, caregivers can help prevent the spread of infection to others and minimize the risk of re-infection to the child. This nursing consideration is crucial in managing impetigo and promoting the child's recovery.
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Following a transsphenoidal hypophysectomy, the nurse should assess the client care fully for which of the following conditions?
- A. Hypocortisolism.
- B. Hyperglycemia
- C. Hypoglycemia
- D. Hypercalcemia
Correct Answer: A
Rationale: Following a transsphenoidal hypophysectomy, the nurse should assess the client carefully for hypocortisolism, also known as adrenal insufficiency. This is because the procedure involves removing the pituitary gland, which plays a critical role in regulating cortisol production by the adrenal glands. Without proper cortisol production, the client may develop symptoms such as weakness, fatigue, low blood pressure, weight loss, and nausea. Monitoring for signs of hypocortisolism is crucial for prompt detection and intervention to prevent adrenal crisis, which can be life-threatening. Hyperglycemia, hypoglycemia, and hypercalcemia are not typically direct concerns following a transsphenoidal hypophysectomy.
A mother calls the school nurse saying that her daughter has developed a school phobia. She has been out of school 3 days. The nurse's recommendations should include which intervention?
- A. Immediately return the child to school.
- B. Explain to the child that this is the last day she can stay home.
- C. Determine the cause of phobia before returning the child to school.
- D. Seek professional counseling before forcing the child to return to school.
Correct Answer: C
Rationale: The appropriate intervention in this situation would be to determine the cause of the school phobia before immediately returning the child to school. School phobia, also known as school refusal, can be triggered by various factors such as bullying, academic stress, separation anxiety, or other psychological issues. By identifying the underlying cause of the phobia, the school nurse can better support the child and provide appropriate interventions to address the specific issues that are contributing to the child's reluctance to attend school. This approach helps ensure that the child receives the necessary support and resources needed to successfully reintegrate into the school environment.
A patient was diagnosed with hiatal hernia. She frequently has regurgitation and a sour taste on his mouth especially after eating large meals. Which action by the client shows understanding of her treatment regimen?
- A. elevate her legs when she is sleeping
- B. drink more fluids with her meals
- C. increase the roughage in her diet
- D. avoid caffeine, alcohol, and chocolate
Correct Answer: D
Rationale: Hiatal hernia is a condition where a part of the stomach pushes up through the diaphragm muscle. Symptoms often include regurgitation of stomach acid into the esophagus, leading to heartburn and a sour taste in the mouth. Avoiding triggers like caffeine, alcohol, and chocolate can help reduce acid reflux and alleviate symptoms. These substances can relax the lower esophageal sphincter and increase stomach acid production, worsening symptoms in patients with hiatal hernia. Therefore, avoiding caffeine, alcohol, and chocolate is a key aspect of managing hiatal hernia symptoms effectively. The other options provided do not directly address the underlying cause of the symptoms experienced by the patient with hiatal hernia.
The nurse interprets this as?
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Metabolic alkalosis
Correct Answer: C
Rationale: Respiratory alkalosis is a condition where there is a decrease in carbon dioxide levels in the blood due to hyperventilation, leading to an increase in pH. In respiratory alkalosis, the body is expelling too much carbon dioxide, causing the blood to become more alkaline. The nurse's interpretation of the situation as respiratory alkalosis suggests that the patient may be breathing rapidly or deeply, resulting in the elimination of excess carbon dioxide and a shift towards alkalosis.
A 17-year-old boy is admitted in sickle cell crisis. Which of the ff. events most likely contributed to the onset of the crisis?
- A. He started a new job last week.
- B. He had seafood for dinner last night.
- C. He walked home in a cold rain
- D. He has not exercised for a week. yesterday.
Correct Answer: C
Rationale: Walking home in a cold rain can trigger a sickle cell crisis in individuals with sickle cell disease. Exposure to cold temperatures or getting wet can lead to vasoconstriction, causing the blood vessels to narrow and slow down blood flow. This reduced blood flow can increase the likelihood of sickle cells sticking together and blocking blood vessels, leading to pain and tissue damage characteristic of a sickle cell crisis. It is essential for individuals with sickle cell disease to avoid exposure to extreme temperatures, including cold rain, to prevent the onset of a crisis.