Nokea
Which should the nurse consider when preparing a school-age child and the family for heart surgery?
- A. Unfamiliar equipment should not be shown.
- B. Let the child hear the sounds of an ECG monitor.
- C. Avoid mentioning postoperative discomfort and interventions.
- D. Explain that an endotracheal tube will not be needed if the surgery goes well.
Correct Answer: B
Rationale: The child and family should be exposed to the sights and sounds of the intensive care unit (ICU). All positive, nonfrightening aspects of the environment are emphasized. The child should be shown unfamiliar equipment and its use demonstrated on a doll. Carefully prepare the child for the postoperative experience, including intravenous (IV) lines, incision, and endotracheal tube.
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Which is/are true?
- A. Babies are able to respond to sounds in utero
- B. Full term babies at birth are unable to follow a large object with their eyes
- C. A 6-week-old infant would be able to follow a large object through an arc of 135°
- D. Growth velocity of head decreases with age
Correct Answer: A
Rationale: Babies can respond to sounds in utero, and head growth velocity does decrease with age. Full-term babies can follow large objects, and a 6-week-old can follow objects through a smaller arc.
The following are recognised in coeliac disease:
- A. Oesophageal carcinoma
- B. Malignant lymphoma
- C. Hyposplenism
- D. Amyloidosis
Correct Answer: C
Rationale: Hyposplenism: Coeliac disease is associated with hyposplenism, which can result in impaired immune responses and increased susceptibility to infections.
A male client complains of pain in his right calf, and the nurse determines that his calf is edematous and deep red. What intervention has the highest priority?
- A. Tell the client to remain in bed
- B. Apply warm compresses to the affected leg.
- C. Administer pain medication as prescribed.
- D. Encourage the client to elevate the affected leg.
Correct Answer: A
Rationale: The symptoms suggest deep vein thrombosis (DVT). Bed rest prevents dislodgment of the clot, reducing the risk of pulmonary embolism.
Two days after a nephrectomy, the client reports abdominal pressure and nausea, which assessment should the nurse implement?
- A. Palpate the abdomen
- B. Measure hourly urine output
- C. Ambulate client in hallway
- D. Auscultate bowel sounds
Correct Answer: D
Rationale: Auscultating bowel sounds helps assess for any bowel obstruction or ileus, which could be contributing to abdominal pressure.
Corneal opacities are seen in:
- A. Marfan's syndrome
- B. Herpes simplex infection
- C. Hurler syndrome
- D. Osteogenesis imperfecta
Correct Answer: C
Rationale: Corneal opacities are a characteristic feature of Hurler syndrome, a type of mucopolysaccharidosis.