A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?
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Solution
The infant received mechanical ventilation for 2 weeks
Option D: Bronchopulmonary dysplasia is an iatrogenic disease caused by therapies such as use of positive-pressure ventilation used to treat lung disease.
The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse?
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Solution
“The seizure may or may not mean your child has epilepsy.”
Option B: There are many possible causes for a childhood seizure. These include fever, central nervous system conditions, trauma, metabolic alterations and idiopathic (unknown).
A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears slightly blue. The appropriate initial action should be to
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Solution
Perform 5 abdominal thrusts
Option C: At this age, the most effective way to clear the airway of food is to perform abdominal thrusts.
A nurse and client are talking about the client’s progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship?
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Solution
Working
Option C: During the working phase, alternative behaviors and techniques are explored. The nurse and the client discuss the meaning behind the behavior.
While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what other behavior?
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Solution
Poor body image
Option B: As the adolescent gains weight, there is a lessening sense of self-esteem and poor body image.
The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which of the following actions would be most appropriate?
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Solution
Administer analgesic therapy as ordered
Option C: The main general objectives in the treatment of a sickle cell crisis is bed rest, hydration, electrolyte replacement, analgesics for pain, blood replacement and antibiotics to treat any existing infection.
An ambulatory client reports edema during the day in his feet and an ankle that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
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Solution
“Do you become short of breath during your normal daily activities?”
Option B: These are the symptoms of right-sided heart failure, which causes increased pressure in the systemic venous system. To equalize this pressure, the fluid shifts into the interstitial spaces causing edema. Because of gravity, the lower extremities are first affected in an ambulatory patient. This question would elicit information to confirm the nursing diagnosis of activity intolerance and fluid volume excess both associated with right-sided heart failure.
The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior?
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Solution
Use patience and a sense of humor to deal with this behavior
Option C: The nurse should help the parents see the negativism as a normal growth of autonomy in the toddler. They can best handle the negative toddler by using patience and humor.
A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?
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Solution
“Would you please clarify what you have written so I am sure I am reading it correctly?”
Option B: Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression of concern for safe practice and a request for clarification without self-depreciation. It reflects the right of the professional to give and receive information.
The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?
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Solution
Coronary artery aneurysms
Option D: Kawasaki Disease involves all the small and medium-sized blood vessels. There is progressive inflammation of the small vessels which progresses to the medium-sized muscular arteries, potentially damaging the walls and leading to coronary artery aneurysms.