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While caring for a patient who is hospitalized for acute gastroenteritis and dehydration, the pediatric nurse notes that the patient's parent keeps packets of herbs by the patient's bedside. Suspecting that the parent may be administering the herbs to the patient, the nurse's first action is to:
- A. ask the parent in a nonjudgmental manner about the herbs.
- B. coordinate a nursing care conference to discuss the patient's plan of care.
- C. discuss the risks of using alternative therapies with the parent.
- D. refer the family to a social worker for possible nonadherence with the healthcare regimen.
Correct Answer: A
Rationale: A nonjudgmental approach encourages open communication and allows the nurse to assess the situation appropriately.
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A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:
- A. Helping the client cope with body image
- B. Maintaining a patent airway.
- C. Preventing injury.
- D. Ensuring adequate nutrition.
Correct Answer: B
Rationale: In a client with esophageal cancer who is experiencing difficulty swallowing, maintaining a patent airway is the highest priority. The client is at risk for aspiration due to the compromised ability to swallow, which could lead to respiratory distress, choking, or aspiration pneumonia. Adequate oxygenation is essential for the client's survival and must be addressed as the priority issue. While coping with body image, preventing injury, and ensuring nutrition are important aspects of care, they are secondary to ensuring the client's airway remains open and clear to prevent respiratory complications.
The nurse is teaching nursing students about shock that occurs in children. What is one of the most frequent causes of hypovolemic shock in children?
- A. Sepsis
- B. Blood loss
- C. Anaphylaxis
- D. Congenital heart disease
Correct Answer: B
Rationale: One of the most frequent causes of hypovolemic shock in children is blood loss. Children are at risk for blood loss due to trauma, surgical procedures, gastrointestinal bleeding, or other conditions that result in significant blood volume reduction. Blood loss leads to a decrease in circulating blood volume, which in turn reduces tissue perfusion and oxygen delivery to vital organs. This results in hypovolemic shock, where the heart is unable to pump sufficient blood to meet the body's needs, leading to organ dysfunction and potentially life-threatening complications. Therefore, recognizing and addressing blood loss promptly is essential in managing hypovolemic shock in children.
Low birth weight or premature infants are screened for anemia at birth and again at the age of
- A. 2 months
- B. 4 months
- C. 6 months
- D. 8 months
Correct Answer: C
Rationale: Anemia screening for low birth weight or premature infants is recommended at 6 months.
The nurse is reviewing the patient's daily PT and INR levels. The PT level is 26 (normal = 9 to 12 seconds). Which of the ff. actions should the nurse take?
- A. Give the next dose of warfarin when it is ordered to be given.
- B. Inform physician before the next dose of warfarin is given. c.Stop the heparin infusion.
- C. Continue monitoring heparin infusion.
Correct Answer: B
Rationale: A PT level of 26 seconds is significantly above the normal range of 9 to 12 seconds. This indicates that the patient's blood is taking much longer to clot than usual, which may put the patient at risk for bleeding. It is important for the nurse to inform the physician before giving the next dose of warfarin because warfarin is a medication that helps prevent blood clots by thinning the blood. However, in this case, the patient's blood is already thin beyond the target range, so giving the next dose of warfarin without physician guidance may further increase the risk of bleeding. The physician may need to adjust the dose or recommend other interventions to manage the patient's PT levels effectively.
When caring for a client, whose being treated for hyperthyroidism, it's important to:
- A. Provide extra blankets and clothing to keep the client warm.
- B. Monitor the client for signs of restlessness, sweating and excessive weight loss during thyroid replacement therapy.
- C. Balance the client's periods of activity and rest.
- D. Encourage the client to be active to prevent constipation.
Correct Answer: B
Rationale: When caring for a client with hyperthyroidism, it is important to monitor the client for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy. Treatment for hyperthyroidism often involves thyroid replacement therapy to restore the balance of thyroid hormones in the body. Monitoring for signs and symptoms of overmedication or undermedication is crucial to ensure the client's health and well-being. Restlessness, sweating, and weight loss can be indicators of an imbalance in thyroid hormone levels and may require adjustments in medication dosage. Regular monitoring and communication with healthcare providers are essential in managing the client's condition effectively.