Nokea
You are evaluating a 2-year-old boy with multiple bruises. Physical examination is unremarkable apart from multiple bruising areas. Lab investigations including coagulation profile are normal. Of the following, bruises that are LEAST likely suggestive of physical abuse is
- A. bruises over the neck
- B. looped extension cord marks on the body
- C. bruises over bony prominences
- D. bruising of the torso
Correct Answer: C
Rationale: Bruises over bony prominences are common in toddlers due to falls and rough play, whereas bruises in unusual locations like the neck or torso are more suspicious for abuse.
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A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?
- A. "Keep the stoma uncovered."
- B. "Keep the stoma dry."
- C. "Have a family member perform stoma care initially until you get used to the procedure."
- D. "Keep the stoma moist."
Correct Answer: B
Rationale: It is important to keep the stoma dry to prevent infection and skin irritation. Excess moisture can lead to skin breakdown around the stoma site, increasing the risk of infection. It is recommended to keep the stoma clean and dry to promote healing and prevent complications.
Which is a common, serious complication of rheumatic fever?
- A. Seizures
- B. Cardiac arrhythmias
- C. Pulmonary hypertension
- D. Cardiac valve damage
Correct Answer: D
Rationale: Rheumatic fever is an inflammatory disease that can develop after a streptococcal infection, such as strep throat. One of the most serious complications of rheumatic fever is cardiac involvement, specifically damage to the heart valves. This occurs due to the body's immune response attacking the heart valves as a result of molecular mimicry between streptococcal antigens and human tissues. The damage to the heart valves can result in conditions like mitral valve stenosis or regurgitation, which can lead to heart failure if not managed appropriately. Therefore, cardiac valve damage is a common and serious complication of rheumatic fever that requires monitoring and treatment to prevent long-term consequences.
Why does the nurse instruct the client to avoid Valsalva maneuvers?
- A. Clients BP will decrease momentarily
- B. Client may lose consciousness
- C. Client may suffer from a myocardial
- D. Clients BP will increase momentarily infarction
Correct Answer: C
Rationale: The nurse instructs the client to avoid Valsalva maneuvers because the client may suffer from a myocardial infarction. The Valsalva maneuver involves forcefully trying to exhale against a closed airway, which can increase intra-thoracic pressure and subsequently increase blood pressure. This can lead to an increased workload on the heart, potentially causing myocardial ischemia or infarction in individuals with underlying heart conditions. Therefore, it is important to avoid Valsalva maneuvers, especially in clients at risk for cardiovascular issues.
A 2-year-old is noted to be drinking from a container filled with kerosene. He immediately coughs, becomes tachypneic, and is brought to the hospital. The best approach to his treatment is to
- A. induce emesis
- B. perform nasogastric tube lavage
- C. instill mineral oil
- D. administer steroids
Correct Answer: E
Rationale: Inducing emesis or performing gastric lavage can increase the risk of aspiration. The best approach is supportive care, including oxygen and monitoring.
A patient is admitted with symptoms of a recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs. Which of the following nursing diagnoses is most appropriate for this patient's plan of care?
- A. Deficient fluid volume
- B. Imbalanced nutrition more than body requirements
- C. Excess fluid volume
- D. Noncompliance
Correct Answer: C
Rationale: The patient's symptoms of recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs are indicative of fluid volume excess. These signs and symptoms suggest that the patient is retaining too much fluid, leading to the edema and congestion in the lungs. The nursing diagnosis of Excess Fluid Volume is appropriate for this patient as it reflects the patient's current physiological state and guides the plan of care to address excess fluid accumulation through interventions such as diuretic therapy, fluid restriction, and monitoring of intake and output. Deficient fluid volume, Imbalanced nutrition more than body requirements, and Noncompliance are not appropriate nursing diagnoses given the patient's presentation of fluid overload.