NCLEX Random
When do you first auscultate for fetal heart rate?
10-12 weeks
The nurse provides care for a pediatric client who is diagnosed with precocious puberty. The child states, "I hate going to school because everyone makes fun of me because I look different." Which action by the nurse is best? A. Tell the child to report those who bully her to the school principal. B. Use role-play to help the child respond to teasing from other children C. Educate the child and family about the physical changes that are occuring D. Refer the client to a psychiatrist for medication therapy for depression and anxiety
B Children who are diagnosed with precocious puberty may develop self-esteem issues because their bodies look different from those of their peers. Additionally, the child may experience teasing from others thus it is essential that the nurse provide the pediatric client with the tools required to address this issue in the child's daily life.
Which blood lab value would the nurse anticipate when providing care for a client who is diagnosed with liver disease? Select all that apply. A. ALT 54 IU/L B. Ammonia 75 mcg/dL C. AST 200 IU/L D. Bilirubin 30 mg/dL E. PT time 21 seconds
B,C,D,E A. Normal range is 7.5 to 55, this is expected. B. Normal range is 6-47. C. Normal is 8-48 D. Normal is 1.71-20.5 E. Normal 12-13 Increased AST and ALT blood levels indicate liver disease as these enzymes are primarily present within the liver, and released in the blood when there is damage or injury. Use the memory trick AABC for the functions of the liver: A - Albumin is produced by the liver; therefore, liver disease can cause a decrease in albumin levels. A - Ammonia, a waste product made by the body during protein digestion, is broken down by the liver and converted to urea, and then expelled by the renal system as urine; therefore, liver disease causes an increase in ammonia leading to hepatic encephalopathy (altered mental status). B - Bile produced by the liver helps cholesterol and bilirubin to exit the body, so we call bile the "Bile bus." In liver disease, bilirubin is increased because the liver is unable to produce the bile necessary to carry the bilirubin, "from the body into the potty." C - Clotting factors are produced by the liver to help the blood coagulate; therefore, a coagulation panel (PT/INR) is also important.
The nurse assesses a client diagnosed with bipolar affective disorder who was prescribed lithium therapy 8 weeks ago. Which client statement requires intervention by the nurse? Select all that apply. A. "I have been quite drowsy since starting this medication" B. "I think I've gained a few pounds since starting this medication" C. "I have had diarrhea, vomiting, and pain in my abdomen for 3 days" D. "I drink water and chew sugar free gum because my mouth is dry" E. "I took naproxen a few days ago to help with a headache"
C, E Normal side effects include drowsiness, weight gain, and dry mouth. Toxicity symptoms include diarrhea, vomiting, stomach pain, and headache. These require follow up by nurse. Patients should also not take NSAIDs as this can increase risk for toxicity.
A few days after a child received a varicella vaccine, the parent reports that the child has pain, slight pink coloration, and 3 small vesicles near the injection site. Which statement by the nurse is response to the child's parent is appropriate? A. Please bring your child in to see the doctor immediately B. Give your child baby aspirin to decrease side effects with the vaccine C. Keep your child away from other children for 30 days so the virus won't spread D. This is a side effect of the vaccine, so just keep the vesicles covered for now.
D The varicella immunization is given to prevent infection of varicella zoster, the cause of chickenpox. Side effects that are expected for this immunization include discomfort, a few vesicles with redness at the site of injection. Aspirin is contraindicated with pediatric clients as it increases risk for Reye syndrome. Discomfort can be treated with acetaminophen
