Nokea
Why must clients who will undergo diagnostic skin test avoid taking antihistamine or cold preparations for at least 48-72 hrs before testing?
- A. Antihistamines may increase the potential for excessive bleeding
- B. Antihistamines may aggravate the allergic reaction
- C. Antihistamines may increase the potential for false negative results
- D. Antihistamines may cause wheezing
Correct Answer: C
Rationale: Antihistamines are medications commonly used to relieve symptoms of allergies, including itching, sneezing, and hives. When a client undergoing a diagnostic skin test for allergies takes antihistamines, it can suppress the body's allergic response, leading to false negative results. This means that the test may not accurately identify all the substances to which the client is allergic, potentially leading to a misdiagnosis. To ensure the accuracy of the skin test, clients are advised to avoid taking antihistamines or cold preparations for at least 48-72 hours before the testing to allow their body to exhibit the appropriate allergic response.
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The nurse would monitor the client for which of the following?
- A. Trousseau's sign
- B. Hypoglycemia
- C. Hypokalamia
- D. Respiratory changes
Correct Answer: A
Rationale: Trousseau's sign is a clinical sign characterized by carpal spasm induced by inflating a blood pressure cuff above the systolic pressure for a few minutes. It is indicative of hypocalcemia, specifically low calcium levels in the blood. Therefore, the nurse would monitor the client for Trousseau's sign to assess for potential hypocalcemia. This could prompt the healthcare provider to order further diagnostic tests or interventions to address the underlying calcium imbalance. Options B, C, and D do not directly relate to monitoring for Trousseau's sign.
Failure to thrive (FTT) is a descriptive term given to malnourished infants and young children who fail to meet expected standards of growth. Of the following, the growth parameter that is usually not affected by malnutrition is
- A. weight
- B. height
- C. weight for height ratio
- D. head circumference
Correct Answer: D
Rationale: Head circumference is less likely to be affected by short-term malnutrition because brain growth is prioritized during infancy and early childhood.
a hospitalized child with nephrosis is receiving high doses of prednisone. which of the following is an appropriate nursing goal related to this?
- A. prevent infection.
- B. stimulate appetite.
- C. detect evidence of edema.
- D. assist in raising osmotic pressure.
Correct Answer: A
Rationale: High doses of prednisone suppress the immune system, putting the hospitalized child at an increased risk for infections. Therefore, an appropriate nursing goal related to this situation would be to prevent infection by implementing measures such as hand hygiene, maintaining a clean environment, and monitoring for signs and symptoms of infection. It is crucial to protect the child from acquiring additional illnesses while undergoing treatment for nephrosis.
Phenylketonuria (PKU) is a genetic disease that results in the body's inability to correctly metabolize:
- A. glucose.
- B. phenylalanine.
- C. phenylketones.
- D. thyroxine.
Correct Answer: B
Rationale: Phenylketonuria (PKU) is a genetic disorder that affects the body's ability to metabolize the amino acid phenylalanine. Individuals with PKU lack an enzyme called phenylalanine hydroxylase, which results in the buildup of phenylalanine in the body. If untreated, high levels of phenylalanine can lead to intellectual disabilities, seizures, and other serious health problems. Therefore, individuals with PKU need to follow a special diet low in phenylalanine to prevent these complications.
Which of the following is an intraoperative outcome for a patient undergoing an inguinal hernia repair?
- A. Verbalizes fears
- B. Demonstrates leg exercises
- C. Maintains skin integrity
- D. Explains deep breathing exercises
Correct Answer: C
Rationale: Intraoperative outcomes refer to the immediate goals and conditions that are assessed during a surgical procedure. Maintaining skin integrity is a crucial intraoperative outcome for a patient undergoing an inguinal hernia repair surgery. This outcome focuses on ensuring that the patient's skin remains intact, without any damage or breakdown during the surgical procedure. It involves proper positioning of the patient, adequate support to vulnerable areas, and meticulous monitoring of the skin throughout the surgery to prevent any pressure injuries or skin trauma. Other outcomes listed, such as verbalizing fears, demonstrating leg exercises, and explaining breathing exercises, are more pertinent to preoperative or postoperative care rather than intraoperative outcomes.