Nokea
You are examining an infant with multiple cutaneous hemangiomas; you suspect involvement of internal organs. The MOST common site of visceral involvement by hemangiomas is
- A. brain
- B. heart
- C. lung
- D. liver
Correct Answer: D
Rationale: Liver is the most common site of visceral involvement by hemangiomas.
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The nurse is instructed to perform preoperative preparation for the management of a client with malignant tumors. Which of the ff is the most important factor of the nursing management plan?
- A. Insertion of an ostomy pouch
- B. Assessing the symptoms of peritonitis
- C. Maintaining the integrity of the urinary
- D. Insertion of a nasogastric tube diversion procedure
Correct Answer: B
Rationale: Peritonitis is a serious and potentially life-threatening condition that can occur as a complication of malignant tumors. It is characterized by inflammation of the lining of the abdomen and can result in severe abdominal pain, tenderness, fever, and other symptoms. Prompt assessment of peritonitis symptoms is crucial for early detection and intervention to prevent further complications and improve patient outcomes. Assessing for peritonitis symptoms should be the priority in the nursing management plan to ensure timely and appropriate care for the client with malignant tumors.
Which of the ff actions should the nurse perform before a client with impaired physical mobility gets up?
- A. Use parallel bars or a walker
- B. Use incontinence pads
- C. Apply an abdominal binder
- D. Use a footboard
Correct Answer: A
Rationale: Before a client with impaired physical mobility gets up, the nurse should ensure that the appropriate assistive device is available and properly set up for the client to use. Using parallel bars or a walker provides support and stability, helping the client maintain balance and prevent falls while standing and walking. This would be the most suitable action to take before assisting the client in getting up to ensure their safety and mobility. Applying incontinence pads, an abdominal binder, or using a footboard are not directly related to the immediate need of assisting the client with impaired physical mobility in getting up.
which of the following is a characteristic in a child with acute lymphocytic leukemia?
- A. fatigability
- B. persistent fever of unknown cause
- C. tendency to bruise easily
- D. all of the above are correct
Correct Answer: D
Rationale: Children with acute lymphocytic leukemia commonly present with a combination of symptoms which can include fatigability, persistent fever of unknown cause, and a tendency to bruise easily. Fatigue is a common complaint in children with leukemia due to anemia caused by decreased production of healthy red blood cells. Persistent fevers can be a sign of infection, anemia, or other complications related to leukemia. Additionally, children with leukemia may have a low platelet count, leading to easy bruising or bleeding tendencies. Therefore, all of the characteristics mentioned in the options are correct for a child with acute lymphocytic leukemia.
Parents tell the nurse that their 1-year-old son often sleeps with them. They seem unconcerned about this. The nurse's response should be based on which statement?
- A. Children should not sleep with their parents.
- B. Separation from parents should be completed by this age.
- C. Daytime attention should be increased.
- D. This is a common and accepted practice, especially in some cultural groups.
Correct Answer: D
Rationale: The correct response is D because it acknowledges that co-sleeping with children, especially infants and toddlers, is a common and accepted practice in various cultural groups. Co-sleeping can have benefits such as promoting bonding and facilitating breastfeeding. However, it is essential for the nurse to educate the parents on safe sleep practices to reduce the risk of Sudden Infant Death Syndrome (SIDS) or other sleep-related accidents. It is important to provide guidance on creating a safe sleep environment for the child if they continue co-sleeping.
An obese Hispanic client, age 65, is diagnosed with type 2 diabetes mellitus. Which statement about diabetes mellitus is true?
- A. Nearly two-thirds of client with diabetes mellitus are over age
Correct Answer: A
Rationale: Diabetes mellitus is a chronic condition that affects people of all ages, but the prevalence increases with age. As people get older, their risk of developing type 2 diabetes mellitus also increases. Research has shown that nearly two-thirds of individuals with diabetes are over the age of 60. Age is a significant risk factor for developing diabetes, especially type 2 diabetes, which is more common in older individuals. Therefore, the statement "Nearly two-thirds of clients with diabetes mellitus are over the age of 60" is true.