Nokea
Which patient should be monitored most closely for dehydration?
- A. The 50-year-old with an ileostomy
- B. The 72-year-old with diabetes mellitus
- C. The 19-year-old with chronic asthma
- D. The 28-year-old with a broken femur
Correct Answer: A
Rationale: A patient with an ileostomy has an increased risk of dehydration because the ileostomy bypasses a significant portion of the small intestine where most of the water absorption occurs. As a result, the patient is more likely to experience fluid and electrolyte imbalances, leading to dehydration. It is important to monitor this patient closely for signs and symptoms of dehydration, such as decreased urine output, dry mouth, dark-colored urine, weakness, dizziness, and confusion, and take appropriate measures to ensure adequate hydration.
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When educating parents regarding known antecedent infections in acute glomerulonephritis, which of the following should the nurse cover?
- A. Scabies
- B. Impetigo
- C. Herpes simplex
- D. Varicella
Correct Answer: B
Rationale: When educating parents regarding known antecedent infections in acute glomerulonephritis, the nurse should cover impetigo. Acute poststreptococcal glomerulonephritis (APSGN) is commonly triggered by a streptococcal infection, such as impetigo or strep throat. Impetigo, a superficial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes, is a common precursor to APSGN in children. Therefore, educating parents about impetigo and its potential link to acute glomerulonephritis is crucial in helping them recognize and manage their child's health effectively.
The nurse is teaching nursing students about childhood skin lesions. Which is an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid?
- A. Cyst
- B. Papule
- C. Pustule
- D. Vesicle
Correct Answer: D
Rationale: A vesicle is an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid. Serous fluid is a clear, watery fluid that can accumulate within the vesicle. Vesicles are commonly seen in conditions such as herpes simplex virus infections (cold sores) and contact dermatitis. It is important for nursing students to understand the characteristics of different skin lesions to accurately assess and provide appropriate care for patients.
A client diagnosed with systemic lupus erythematosus (SLE) comes to the emergency department with severe back pain. She reports that she first felt pain after manually opening her garage door and that she is taking prednisone daily. When adverse effect of long-term corticosteroid therapy is most likely responsible for the pain?
- A. Hypertension
- B. Muscle wasting
- C. Osteoporosis
- D. Truncal obesity
Correct Answer: C
Rationale: Osteoporosis is the most likely adverse effect of long-term corticosteroid therapy responsible for the severe back pain experienced by the client with systemic lupus erythematosus (SLE). Corticosteroids such as prednisone can lead to bone resorption and calcium loss, resulting in weakened bones and increased risk of fractures. Back pain in this case could be a sign of vertebral compression fractures due to osteoporosis induced by prolonged corticosteroid use. It is important for healthcare providers to monitor bone health in patients on long-term corticosteroid therapy and consider strategies to prevent or manage osteoporosis.
The LEAST helpful advice for a 10-month-old baby refusing spoon feeding is
- A. respect infant independence
- B. offer softer diet
- C. use 2 spoons (1 for child and 1 for parent)
- D. use finger foods
Correct Answer: B
Rationale: Offering softer diet may not address refusal due to developmental factors.
Which of the following instructions should Nurse Cheryl include in her teaching plan for the parents of Reggie with otitis media?
- A. Placing the child in the supine position to bottle-feed
- B. Giving prescribed amoxicillin (Amoxil) on an empty stomach
- C. Cleaning the inside of the ear canals with cotton swabs
- D. Avoiding contact with people who have upper respiratory tract infections
Correct Answer: D
Rationale: Nurse Cheryl should include in her teaching plan for Reggie's parents to avoid contact with people who have upper respiratory tract infections. Otitis media is often caused by upper respiratory infections, and exposure to individuals with such infections can increase the risk of exacerbating Reggie's condition or causing recurrent infections. Implementing measures to minimize exposure can help prevent further complications and promote faster recovery for Reggie. Placing the child in the supine position to bottle-feed may increase the likelihood of fluid entering the middle ear, worsening the otitis media. Giving amoxicillin on an empty stomach is not recommended as it can cause gastrointestinal upset and reduce absorption; instead, it should be given with food to enhance efficacy. Cleaning the inside of the ear canals with cotton swabs can be harmful and may cause damage or introduce infection, making it an inappropriate practice in managing otitis media.