Nokea
Will is being assessed by Nurse Lucas for possible intussusception; which of the following would be least likely to provide valuable information?
- A. Abdominal palpation
- B. Family history
- C. Pain pattern
- D. Stool inspection
Correct Answer: B
Rationale: When assessing a patient like Will for possible intussusception, the least likely to provide valuable information would be the family history. While family history can help identify potential genetic predispositions or conditions that may contribute to a patient's current health concerns, in this case, the focus is on Will's immediate symptoms and diagnostic indicators related to possible intussusception. Abdominal palpation, pain pattern assessment, and stool inspection are more directly relevant to evaluating Will's current condition and determining the likelihood of intussusception. Family history, while important in a broader health context, would be least likely to provide immediate insights into Will's specific situation with intussusception.
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Poor prognostic factors in Hodgkin lymphoma include all the following EXCEPT
- A. age of more than 15 year at the time of diagnosis
- B. stage IV disease
- C. manifested by positron emission tomography (PET) scan positivity
- D. poor response to therapy
Correct Answer: A
Rationale: Older age is generally considered a poor prognostic factor, but not necessarily worse than other listed options.
The nurse is preparing an in-service education to staff about atraumatic care for pediatric patients. Which intervention should the nurse include?
- A. Prepare the child for separation from parents during hospitalization by reviewing a video.
- B. Prepare the child before any unfamiliar treatment or procedure by demonstrating on a stuffed animal.
- C. Help the child accept the loss of control associated with hospitalization.
- D. Help the child accept pain that is connected with a treatment or procedure.
Correct Answer: B
Rationale: Atraumatic care for pediatric patients aims to minimize emotional and psychological distress during hospitalization or medical procedures. Option B, preparing the child before any unfamiliar treatment or procedure by demonstrating it on a stuffed animal, is an appropriate intervention. This technique allows the child to understand what will happen, reduces fear of the unknown, and promotes a sense of control. By using a stuffed animal as a teaching tool, the nurse can provide clear information to the child in a non-threatening way, helping to alleviate anxiety and stress. This intervention encourages trust between the child and healthcare provider and promotes a positive healthcare experience for the pediatric patient.
The nurse in the postoperative unit prepares to receive a client after a balloon angioplasty of the carotid artery. Which of the ff items of priority should the nurse keep at the bedside for such client?
- A. Blood pressure apparatus
- B. IV infusion stand
- C. Call bell
- D. Endotracheal intubation
Correct Answer: A
Rationale: Having a blood pressure apparatus at the bedside is a priority for a client following a balloon angioplasty of the carotid artery. Monitoring blood pressure closely is essential to assess for any signs of complications such as bleeding or thrombosis after the procedure. Rapid identification and management of any changes in blood pressure are crucial in the immediate postoperative period to ensure the client's safety and well-being. It allows the nurse to promptly intervene if there are any signs of complications, helping to prevent further harm to the client.
Which of the ff adverse reactions may occur when a client is taking danazol (Danocrine) for fibrocystic breast disease?
- A. Nausea
- B. Amenorrhea
- C. Confusion
- D. Hypotension
Correct Answer: B
Rationale: Danazol (Danocrine) is a synthetic androgen that is used to treat conditions such as fibrocystic breast disease. One of the known adverse effects of danazol is the development of amenorrhea, which refers to the absence of menstrual periods. This occurs because danazol suppresses ovarian function by inhibiting the release of gonadotropins, leading to decreased production of estrogen and progesterone. Amenorrhea associated with danazol use is typically reversible upon discontinuation of the medication. Nausea, confusion, and hypotension are not common adverse reactions associated with danazol use for fibrocystic breast disease.
For a patient who is being discharged on digoxin, the nurse should include which of the ff. in an explanation to the patient on the signs and symptoms of digoxin toxicity?
- A. Poor appetite
- B. Halos around lights
- C. Constipation
- D. Tachycardia
Correct Answer: B
Rationale: Digoxin toxicity can manifest in various ways, but one common sign is the presence of visual disturbances such as seeing halos around lights. This is due to digoxin's effect on the optic nerve. Patients experiencing halos around lights should seek medical attention promptly as it may indicate a serious reaction to the medication. The other options (poor appetite, constipation, tachycardia) may occur with digoxin toxicity as well, but the visual disturbance of halos around lights is a classic and important sign to be aware of.