Nokea
Why are rectal temperatures not recommended in the newborn?
- A. They are inaccurate.
- B. They do not reflect core body temperature.
- C. They can cause perforation of rectal mucosa.
- D. They take too long to obtain an accurate reading.
Correct Answer: C
Rationale: Rectal temperatures are not recommended in newborns because they can potentially cause perforation of the rectal mucosa. Newborns have fragile, delicate tissues in the rectal area, and the insertion of a rectal thermometer may lead to injury or damage to the mucosal lining. It is important to exercise caution and use alternative methods for taking temperatures in newborns to avoid any harm or discomfort.
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For a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?
- A. "Client verbalizes feelings of anxiety."
- B. "Client doesn't guess at prognosis."
- C. "Client uses any effective method to reduce tension."
- D. "Client stops seeking information."
Correct Answer: C
Rationale: The expected outcome that would be appropriate for a client with newly diagnosed cancer experiencing anxiety related to the threat of death would be "Client uses any effective method to reduce tension." This outcome focuses on the client actively engaging in coping strategies to reduce their anxiety. It is important for the client to actively participate in managing their anxiety by utilizing various methods to promote relaxation and reduce tension. It is a more proactive and empowering goal compared to simply verbalizing feelings of anxiety or stopping seeking information. By actively using effective methods to reduce tension, the client is taking steps to improve their emotional well-being and cope with the anxiety related to the cancer diagnosis.
Which chromosomal abnormality is often characteristic of infantile ALL?
- A. t(4;11)
- B. t(12;21)
- C. t(9;22)
- D. t(1;19)
Correct Answer: A
Rationale: The t(4;11) translocation is commonly found in infantile ALL and is associated with a poor prognosis.
As the nurse collects data on a patient, which of the following is a symptom that may be found that the patient with anaphylaxis may be experiencing?
- A. Dermatitis
- B. Sinusitis
- C. Delirium
- D. Wheezing
Correct Answer: D
Rationale: Wheezing is a common symptom of anaphylaxis, along with other signs such as difficulty breathing, chest tightness, coughing, and throat swelling. Wheezing is caused by the constriction of the airways due to the body's extreme immune response to the allergen, leading to difficulty in breathing and wheezing sounds during respiration. It is important for healthcare professionals to recognize wheezing as a symptom of anaphylaxis and respond promptly with appropriate interventions, such as administering epinephrine and providing respiratory support.
A child with thalassemia was given deferoxamine (Desferal); which of the following should alert the nurse to notify the physician?
- A. Decreased hearing
- B. Hypertension
- C. Red urine
- D. Vomiting
Correct Answer: A
Rationale: Deferoxamine is a chelating agent used to treat iron overload in patients such as those with thalassemia. One of the serious side effects of deferoxamine is ototoxicity, which can manifest as decreased hearing or ringing in the ears. Therefore, if a child with thalassemia who is taking deferoxamine experiences a decrease in hearing, the nurse should promptly notify the physician for further evaluation and possible adjustment of the treatment plan to prevent further hearing damage. Hypertension, red urine, and vomiting are possible side effects of deferoxamine, but decreased hearing is the most concerning side effect that requires immediate attention due to the risk of permanent damage.
Which of the following is the most numerous type of white blood cell (WBC)?
- A. Neutrophil
- B. Basophil
- C. Eosinophil
- D. Lymphocyte
Correct Answer: A
Rationale: Neutrophils are the most numerous type of white blood cell (WBC) in the body, comprising about 60-70% of the total WBC count. They are a critical component of the immune system, playing a key role in fighting bacterial infections through phagocytosis (engulfing and destroying pathogens). Neutrophils are known for their rapid response to infections and are often the first responders to sites of inflammation. Their abundance and rapid mobilization make them essential in the body's defense against harmful pathogens.