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ACCURATE AND VERIFIED QUESTIONS AND ANSWERS FOR
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Whatinstructionshouldthenurseprovidetheparents ofa3-year-oldboywith aBMI-for-ageat the 97th
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percentile?
x,
Yourchild is tall forhis age, so be sure he gets plentyto eat to stayhealthy.
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Yourchildisoverweight forhisageandsize,sohelphimselectmorehealthyfoods. Your
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child's weight is in the high range, but is probably normal for his body build.
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Yourchild has verystrong bones, so continue to maintain the same diet.
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Yourchild is overweight forhis ageand size, so help him select morehealthyfoods.
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Rationale:
Children with a BMI-for-age at or above the 95th percentile are considered overweight, and at riskfor
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obesityandalltheassociatedhealthproblems. Thenurseshouldofferrecommendations for healthy
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eating and exercise.
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When should the nurse conduct an Allen's test?
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When pulmonary artery pressures are obtained.
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Prior to attemptinga cardiacoutput calculation.
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To assess forpresenceof a deepvein thrombus in the leg. Just
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before arterial blood gasses are drawn peripherally.
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Justbeforearterial blood gasses are drawn peripherally.
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Rationale:
TheAllen'stestshouldbeperformedpriortopuncturingtheradial arterytoobtainabloodgas specimen to
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determine patency of the ulnar artery in the selected extremity. To perform an Allen's test the client's
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hand is formed into a fist while the nurse compresses the ulnar artery.
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,Compression continues whilethe fist is opened. If blood perfusion through the radial arteryis adequate,
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the hand should flush and resume its normal pinkish coloration.
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In earlysepticshockstates,whatistheprimarycauseofhypotension?
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Peripheral vasoconstriction.
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Peripheralvasodilation. x,
Cardiac failure.
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A vagal response. Peripheral
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vasodilation.
x,
,Rationale:
Toxinsreleasedbybacteriainsepticshockcreatemassiveperipheralvasodilationandincrease
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microvascular permeability at the site of the bacterial invasion.
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Aclientwithbleedingesophagealvaricesreceivesvasopressin IV.Whichshouldthenurse monitor for
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during the IV infusion of this medication?
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Chest pain and dysrhythmia. x, x, x,
Vasodilation of the extremities.
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Hypotension and tachycardia.
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DecreasingGIcrampingandnausea.
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Chest pain and dysrhythmia. x, x, x,
Rationale:
Inlargedoses,vasopressinmayproduceincreased bloodpressure,coronaryinsufficiency, myocardial
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ischemia or infarction, and dysrhythmia.
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Thewifeof aclientdiagnosedwithParkinson's diseasetellsthenursethatherhusband ishaving trouble
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swallowing and she is afraid he is going to choke. Which intervention should the nurse implement?
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Offer the wife assurance that difficulty with swallowing is usually temporary.
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Encouragethecoupleto considerinsertionofanasogastrictubefortubefeedings. Teach
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the wife to thicken all liquids and serve primarily semi-solid foods.
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Instruct wife to give carbidopa-levodopa 30-minutes before each meal.
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x, Teachthewifetothickenallliquidsandserveprimarilysemi-solidfoods.
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x, Rationale:
DysphagiaisusuallyachronicproblemfortheclientwithParkinson's disease.Asemi-soliddiet with x, x, x, x, x, x, x, x, x, x, x, x, x, x, x,
thick liquids is easier to swallow than solid foods.
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Several clients on a busy antepartum unit are scheduled for procedures that require informed consent.
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Whichsituationshouldthenurseexplorefurtherbeforewitnessingtheclient'ssignature on the consent
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form?
x,
A15-year-oldprimigravidawhohasbeenself-supportingforthepast6months. The
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obstetrician explained a procedure that a neurologist will perform.
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Theclient was medicated forpain with a narcotic analgesic IM 6 hours ago.
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Theclientisilliteratebutverbalizesunderstandingandconsentfortheprocedure. The
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x, obstetrician explained a procedure that a neurologist will perform. x, x, x, x, x, x, x, x,
, Rationale:
The individual who is ultimately responsible for the procedure should provide the information
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necessaryforinformedconsent,sowhenanobstetricianexplainstheprocedurescheduledtobe
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