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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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 talking to the parents of a child with pediculosis capitis. Which should the nurse include when explaining how to manage pediculosis capitis?
- A. "You will need to cut the hair shorter if infestation and nits are severe."
- B. "You can distinguish viable from nonviable nits, and remove all viable ones."
- C. "You can wash all nits out of hair with a regular shampoo."
- D. "You will need to remove nits with an extra-fine-tooth comb or tweezers."
Correct Answer: D
Rationale: The nurse should include in the explanation that in managing pediculosis capitis, it is necessary to remove nits with an extra-fine-tooth comb or tweezers since nits are attached to the hair shaft and can be difficult to wash out with regular shampoo. Removing the nits is crucial to prevent reinfestation, as they can hatch and start the cycle again. Cutting the hair shorter is not necessary unless the infestation is severe. It is important to distinguish viable (live) nits from nonviable (dead) ones and remove only the viable ones as the nonviable ones do not pose a threat of reinfestation.
How does nosocomial pneumonia occur?
- A. In a healthcare setting
- B. Within 48hrs of admission to a healthcare
- C. In the immunocompromised host facility
- D. In a community setting
Correct Answer: A
Rationale: Nosocomial pneumonia occurs in a healthcare setting. It is a type of pneumonia that is contracted during a hospital stay or other healthcare facilities. The risk of developing nosocomial pneumonia is higher in patients who are already hospitalized due to various medical conditions, surgeries, or use of medical devices like ventilators. The infection can be caused by different types of bacteria, viruses, or fungi present in the healthcare environment. Preventive measures, such as proper hand hygiene, infection control practices, and minimizing the use of invasive devices, are crucial in reducing the incidence of nosocomial pneumonia.
A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that adaptive immunity is provide by which type of white blood cell?
- A. Neutrophil
- B. Monocyte
- C. Basophil
- D. Lymphocyte
Correct Answer: D
Rationale: Lymphocytes are the type of white blood cells that provide adaptive immunity. There are two main types of lymphocytes: B cells and T cells. B cells produce antibodies that can specifically recognize and target certain pathogens (including HIV), while T cells have various functions in the immune response, such as directly killing infected cells or helping other immune cells. Adaptive immunity is characterized by the body's ability to remember specific pathogens and mount a targeted response upon subsequent exposures. In the context of HIV and AIDS, understanding the role of lymphocytes in adaptive immunity is essential for the client to comprehend how the virus affects the immune system and why immune function becomes compromised over time.
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.