Nokea
Which of the following findings should the nurse expect?
- A. Pinpoint pupils
- B. Ataxia
- C. Hyperactive reflexes
- D. Hypothermia
Correct Answer: B
Rationale: The correct answer is B: Ataxia. Ataxia is a neurological finding characterized by lack of coordination and unsteady gait, commonly seen in conditions like cerebellar dysfunction. Pinpoint pupils (A) suggest opioid toxicity, hyperactive reflexes (C) indicate possible hyperthyroidism or CNS injury, and hypothermia (D) is associated with hypothyroidism or hypothermia. Ataxia is the most relevant finding in this context, indicating a potential neurological issue.
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Which of the following findings should the nurse report to the provider?
- A. Drainage from the chest tube of 22 mL in the last hour
- B. Urine output of 15 mL in the last 2 hr
- C. Skin temperature 36° C (96.8° F)
- D. Pedal and posterior tibial pulses of 2+
Correct Answer: B
Rationale: The correct answer is B: Urine output of 15 mL in the last 2 hr. Inadequate urine output can indicate renal impairment or inadequate fluid intake. This is a critical finding that needs immediate attention to prevent further complications like acute kidney injury. A: Drainage from the chest tube of 22 mL in the last hour is within the normal range. C: Skin temperature of 36°C (96.8°F) is within normal limits. D: Pedal and posterior tibial pulses of 2+ indicate normal circulation.
Which of the following statements should the nurse make?
- A. You need to come back in a week for retesting.
- B. I have to notify the public health department.
- C. I have to contact your parents.
- D. Let's review the side effects of metronidazole.
Correct Answer: B
Rationale: The correct answer is B: I have to notify the public health department. This statement is crucial in cases of reportable diseases to prevent the spread of infection. Notifying the public health department is a legal and ethical responsibility to ensure appropriate measures are taken. Choice A is incorrect because it lacks urgency in notifying the proper authorities. Choice C is incorrect as contacting the patient's parents may not be necessary in this situation. Choice D is incorrect as reviewing side effects of metronidazole is not the priority when dealing with a reportable disease.
Which of the following statements by the guardian indicates an understanding of the teaching?
- A. I will ensure that my child consumes a high-calorie diet.
- B. I will expect my child to need annual sweat chloride testing.
- C. I will have my child chew the pancrelipase medication before eating.
- D. I will administer dormase alfa every 4 hours for wheezing.
Correct Answer: A
Rationale: The correct answer is A because ensuring the child consumes a high-calorie diet demonstrates an understanding of the teaching regarding managing cystic fibrosis, a condition that requires a high-calorie intake to maintain weight and overall health. This statement aligns with the need for nutritional support in cystic fibrosis management.
Choice B is incorrect because annual sweat chloride testing is not related to dietary management. Choice C is incorrect as chewing pancrelipase medication before eating is not necessary for understanding the teaching about cystic fibrosis. Choice D is incorrect as administering dormase alfa every 4 hours for wheezing does not pertain to dietary requirements in cystic fibrosis.
Which of the following findings should the nurse recognize as being consistent with hyperglycemia?
- A. Sweating
- B. Tremors
- C. Pallor
- D. Thirst
Correct Answer: D
Rationale: The correct answer is D: Thirst. Hyperglycemia results in elevated blood sugar levels, leading to increased osmolality and dehydration, triggering thirst as the body attempts to dilute the blood. Sweating (A), tremors (B), and pallor (C) are not typically associated with hyperglycemia. Sweating is more commonly seen in hypoglycemia, tremors can be a sign of low blood sugar, and pallor is not a direct symptom of high blood sugar levels.
Which of the following clients should the nurse assess first?
- A. A toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus of nafcillin
- B. An adolescent who is in skin traction and reports a pain level of 7 on a scale from 0 to 10
- C. An adolescent who has sickle cell anemia and slurred speech
- D. A toddler who has a partial-thickness burn on his right hand and requires a dressing change
Correct Answer: C
Rationale: The correct choice is C. The nurse should assess the adolescent with sickle cell anemia and slurred speech first because slurred speech could indicate a potential stroke or other serious neurological complication related to sickle cell disease. It is crucial to prioritize neurological symptoms as they may lead to life-threatening complications if not addressed promptly. Assessing for signs of stroke and providing immediate intervention is essential in this situation. Choices A, B, and D involve pain management and wound care, which are important but not as urgent as addressing potential neurological complications. Therefore, assessing the client with slurred speech is the priority to ensure timely and appropriate intervention.