Nokea
Which of the ff symptoms should a nurse assess in a client when implementing interventions for trauma to the upper airway?
- A. Pain when talking
- B. Increased nasal swelling
- C. Burning in the throat
- D. Presence of laryngospasm INFECTIONS OF THE LOWER RESPIRATORY AIRWAY
Correct Answer: D
Rationale: When implementing interventions for trauma to the upper airway, it is crucial for the nurse to assess for the presence of laryngospasm. Laryngospasm is a sudden spasm of the vocal cords that may cause difficulty breathing and in severe cases, complete airway obstruction. It is a serious and potentially life-threatening complication that can occur following upper airway trauma. Therefore, prompt recognition and treatment of laryngospasm are essential to ensure adequate oxygenation and ventilation for the client. Pain when talking, increased nasal swelling, and burning in the throat may also be symptoms encountered in upper airway trauma, but the presence of laryngospasm signifies a more critical condition requiring immediate intervention.
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Although the etiology of hepatoblastoma is unknown, there are many associated risk factors for development of hepatoblastoma EXCEPT
- A. Beckwith-Wiedemann syndrome
- B. familial adenomatous polyposis syndrome
- C. prematurity
- D. low birth weight
Correct Answer: E
Rationale: Hepatitis C infection is not a recognized risk factor for hepatoblastoma.
What is the care priority for a newborn with bladder exstrophy and a malformed pelvis?
- A. Change the diaper frequently and assess for skin breakdown.
- B. Keep the exposed bladder open in a warm, dry environment.
- C. Offer formula for growth and fluid management.
- D. Cluster care to allow the child uninterrupted sleep and strength for upcoming surgical repair.
Correct Answer: D
Rationale: Minimizing disturbances (clustering care) helps prevent infection and allows the infant to conserve energy before surgical repair.
Which of the ff. safety instructions should the nurse give a patient who has temporarily dilated pupils?
- A. Keep eyes closed
- B. Wear sunglasses
- C. Do not drive for 8 hours
- D. Avoid caffeinated beverages
Correct Answer: B
Rationale: Dilated pupils can cause increased sensitivity to light, leading to discomfort or visual disturbances. Wearing sunglasses can help protect the eyes from bright light and reduce potential discomfort for the patient. This safety instruction is important to promote the patient's comfort and prevent any potential harm due to light sensitivity.
Parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse's reply should be based on which statement?
- A. The child needs opportunities to play with peers.
- B. The child needs to understand that peers' activities are too strenuous.
- C. Parents can meet all of the child's needs.
- D. Constant parental supervision is needed to avoid overexertion.
Correct Answer: A
Rationale: The nurse's reply should be based on the statement that "the child needs opportunities to play with peers." It is important for children to engage in play and social interactions with their peers for their overall development, including social, emotional, cognitive, and physical growth. By allowing the child with congenital heart disease to play with other children, under appropriate supervision, the child can still have enriching experiences while ensuring their safety and well-being. It is essential to strike a balance between enabling the child to participate in activities and managing any potential risks associated with their condition. A supportive environment that encourages play and socialization with peers can contribute positively to the child's development and quality of life.
A client with acquired immunodeficiency syndrome (AIDS) is receiving zidovudine (azidothymidine, AZT [Retrovir]). To check for adverse drug effects, the nurse should monitor the results of laboratory test?
- A. RBC count
- B. Serum calcium
- C. Fasting blood glucose
- D. Platelet count
Correct Answer: D
Rationale: Zidovudine (azidothymidine, AZT [Retrovir]) is an antiretroviral medication used to treat human immunodeficiency virus (HIV) infection. One of the potential adverse effects of zidovudine is bone marrow suppression, which can lead to decreased production of blood cells including platelets. Monitoring the platelet count is essential because a low platelet count (thrombocytopenia) can result in an increased risk of bleeding and bruising. Therefore, regular monitoring of platelet count is crucial to detect and manage this potential adverse effect promptly in patients receiving zidovudine therapy. Monitoring other laboratory tests such as RBC count, serum calcium, and fasting blood glucose may also be important for assessing overall health status, but platelet count monitoring takes priority due to the risk of thrombocytopenia associated with zidovudine therapy.