Nokea
Which of the ff nursing interventions is involved when caring for a client with influenza?
- A. Maintaining airborne transmission
- B. Oxygen administration
- C. Immediate recognition of respiratory
- D. Complete bed rest distress
Correct Answer: C
Rationale: When caring for a client with influenza, immediate recognition of respiratory distress is crucial. Influenza can lead to respiratory complications such as pneumonia, which may result in respiratory distress. Early detection of symptoms such as increased respiratory rate, shortness of breath, and chest pain can help in providing prompt intervention and preventing further complications. Therefore, the nursing intervention involved in caring for a client with influenza is to closely monitor the respiratory status and quickly recognize any signs of respiratory distress. This proactive approach can potentially save the client's life and improve outcomes.
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Neuroblastoma can be associated with paraneoplastic syndromes. All the following features are paraneoplastic EXCEPT
- A. uncontrollable jerking movements
- B. cerebellar ataxia and increased body coordination
- C. unilateral ptosis, myosis, and anhidrosis
- D. profound secretory diarrhea
Correct Answer: B
Rationale: Increased body coordination is not a typical feature of neuroblastoma-associated paraneoplastic syndromes.
The nurse is caring for a child with acute renal failure. Which clinical manifestation should the nurse recognize as a sign of hyperkalemia?
- A. Dyspnea
- B. Seizure
- C. Oliguria
- D. Cardiac arrhythmia
Correct Answer: D
Rationale: Hyperkalemia is a condition characterized by elevated levels of potassium in the blood. This can have serious effects on the heart, leading to cardiac arrhythmias which can be life-threatening. In acute renal failure, the kidneys are not able to properly regulate potassium levels in the blood, leading to a potential buildup of potassium, resulting in hyperkalemia. The nurse should recognize cardiac arrhythmias as a critical sign of hyperkalemia in a child with acute renal failure and take prompt action to address this electrolyte imbalance. Dyspnea, seizure, and oliguria are not typically directly correlated with hyperkalemia.
A child is brought to the emergency department experiencing an anaphylactic reaction to a bee sting. While an airway is being established, the nurse should prepare which medication for immediate administration?
- A. Diphenhydramine (Benadryl)
- B. Dobutamine (Dobutarex)
- C. Epinephrine (Adrenalin)
- D. Calcium chloride (calcium chloride)
Correct Answer: C
Rationale: In the management of anaphylaxis, the immediate medication of choice for administration is epinephrine. Epinephrine is a potent vasoconstrictor and bronchodilator which helps restore blood pressure and open up the airways during an anaphylactic reaction. It is the first-line treatment to reverse the potentially life-threatening effects of an allergic reaction. Other medications, like diphenhydramine or dobutamine, may be used as adjuncts later in the treatment, but epinephrine is crucial for immediate administration to stabilize the child's condition.
Early this morning a client had a subtotal thyroidectomy. During evening rounds, the nurse assesses the client, who has now nausea, a temperature of 105F (40.5C), tachycardia, and extreme restlessness. What is the most likely cause of these signs?
- A. Diabetic ketoacidosis
- B. Hypoglycemia
- C. Thyroid crisis
- D. Tetany
Correct Answer: C
Rationale: The signs and symptoms described - nausea, elevated temperature, tachycardia, and extreme restlessness - are indicative of a thyroid crisis, also known as thyroid storm. A thyroid storm is a life-threatening condition that can occur after thyroid surgery such as a subtotal thyroidectomy. It is characterized by an exaggerated state of hyperthyroidism, leading to a surge of thyroid hormones in the bloodstream. This can result in severe symptoms such as high fever, tachycardia, nausea, agitation, and even confusion or delirium.
60 year-old Mrs. Torres arrived just in time for her doctor's appointment. She complains of pain and stiffness in her back. She is suspected of having osteoporosis. Nurse Ariane will inform Mrs. Torres that the primary complication of osteoporosis is:
- A. Increased trabeculae
- B. poor posture
- C. chronic pain
- D. fractures
Correct Answer: D
Rationale: The primary complication of osteoporosis is fractures. Osteoporosis is a condition characterized by low bone mass and deterioration of bone tissue, leading to increased bone fragility and susceptibility to fractures. Fractures, especially in the spine, hip, and wrist, are common complications of osteoporosis and can significantly impact an individual's quality of life. Patients with osteoporosis are at an increased risk of fractures from minor trauma or even during normal daily activities. Therefore, preventing fractures is a key focus in the management of osteoporosis to minimize pain, disability, and complications associated with bone fractures.