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Which would be best for the nurse to use when determining the temperature of a preterm infant under a radiant heater?
- A. Axillary sensor TestBankWorld.org
- B. Tympanic membrane sensor
- C. Rectal mercury glass thermometer
- D. Rectal electronic thermometer
Correct Answer: B
Rationale: A tympanic membrane sensor or tympanic thermometer is the best option for determining the temperature of a preterm infant under a radiant heater. Tympanic thermometers are quick and non-invasive, making them ideal for use in neonatal care. They provide accurate readings by measuring the infrared heat waves coming from the eardrum. This method is preferred over other options like axillary sensors, rectal mercury thermometers, and rectal electronic thermometers, which may not be as efficient or suitable for use with preterm infants.
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A client is admitted to an acute care facility with a myocardial infarction. During the admission history, the nurse learns that the client also has hypertension and progressive systemic sclerosis. For a client with this disease, the nurse is most likely to formulate which nursing diagnosis?
- A. Risk for impaired skin integrity
- B. Imbalanced nutrition: Risk for more than
- C. Constipation body requirements
- D. Ineffective thermoregulation
Correct Answer: A
Rationale: For a client with progressive systemic sclerosis, also known as Scleroderma, the nurse is most likely to formulate a nursing diagnosis related to the risk for impaired skin integrity. Scleroderma is a chronic connective tissue disease that can lead to changes in skin texture and thickness, making the skin more prone to breakdown, ulcers, and impaired wound healing. Therefore, assessing and addressing the risk for impaired skin integrity is essential to prevent complications in clients with Scleroderma. While the other options may also be relevant considerations for this client, the priority nursing diagnosis in this case would be related to maintaining skin integrity.
Which is true of a Wilms tumor? (Select all that apply.)
- A. It is also referred to as neuroblastoma.
- B. It is most commonly seen between the ages of 2 and 5 years.
- C. It can occur on its own or be associated with congenital anomalies.
- D. It is a slow-growing tumor.
Correct Answer: C
Rationale: Wilms tumor typically occurs in children aged 2-5 years and may be associated with congenital anomalies. It is not the same as neuroblastoma, and its prognosis is generally good with treatment.
A 3-year-old female is hospitalized for a femur fracture. As her nurse, what nursing action would help foster the child's sense of autonomy?
- A. Allow the child to choose what time to take her oral antibiotics.
- B. Allow the child to have a doll for medical play.
- C. Allow the child to administer her own dose of Keflex (cephalexin) via oral syringe.
- D. Allow the child to watch age-appropriate videos.
Correct Answer: B
Rationale: Allowing preschoolers to participate in actions for which they are capable is an excellent way to enhance their sense of autonomy.
Hemodynamic monitoring by means of a multilumen pulmonary artery catheter can provide detailed information about:
- A. Preload
- B. Afterload
- C. Cardiac output
- D. All of the above
Correct Answer: D
Rationale: A multilumen pulmonary artery catheter, also known as a Swan-Ganz catheter, is used for advanced hemodynamic monitoring. It is inserted through a central line and positioned in the pulmonary artery to provide detailed information about various hemodynamic parameters including preload, afterload, and cardiac output.
Which of the ff should the nurse identify as the earliest symptom of heart failure in many older clients?
- A. Increased urine output
- B. Dyspnea on exertion
- C. Swollen joints
- D. Nausea and vomiting
Correct Answer: B
Rationale: Dyspnea on exertion is often identified as the earliest symptom of heart failure in many older clients. This symptom occurs due to the heart's inability to pump blood efficiently, leading to a buildup of fluid in the lungs. As a result, individuals may experience shortness of breath when engaging in physical activity or even at rest. Monitoring for dyspnea on exertion can aid in the early detection and management of heart failure in older clients. Other symptoms, such as increased urine output, swollen joints, and nausea/vomiting, may also occur in heart failure, but dyspnea on exertion is typically considered one of the earliest signs to manifest.