Most reliable early indicator of myocardial insult would be
* Troponin T and I
rationale: Troponin I and Troponin T are proteins in the striated cells of cardiac tissue and are therefore unique markets for cardiac damage; elevations occur within 1 hour of a myocardial infarction and persist for 7 to 15 days.
Creatine kinas (CK) isoenzyme levels, especially the MB subunit, begin to rise wintin 3 to 6 hours, peak in 12 to 18 hours and are elevated for 48 hours after the occurence of the infarct.
Client has had myocardial infarction develops cardiogenic shock, when assessing this client the nurse would expect to find:
* Warm moist skin
rationale: The skin becomes cool and paale as blood shunts from the peripheral blood vessels to the vital organs.
Possibility of death from complications always accompanies an acute MI. The nurse should monitor the client for during the first 48 hours is:
* Ventricular tacycardia
rationale: At least one half of all deaths occur from the life-threatening dysrhythmia of ventricular tacycardia.
Because a client with MI can develop left ventricular failure, the nurse should assess this client for:
*Paroxysmal nocturnal dyspnea
L = LUNGS
R = ExTREMITIES
Dyspnea at night, which usually requires the assumption of the orthopneic position, is a sign of left ventricular failure; orthopnea, a compensatory mechanism, limits venous return, which decrease pulmonary congestion and promotes ventilation, easing the dyspnea.
What would pose the greatest threat to the baby's health with Down Syndrome?
Rationale: Respiratory infection is most common in children with Down Syndrome (secondary hypotonia and ineffective airway clearance) and is the leading cause of death in children with Down Syndrome
Newborn with Hypospadias, nurse expects to observe:
*Urethral opening located along the ventral surface of the penis.
A Toddler who was hospitalized with AIDS and is stroking a dirty, torn blanket. The nurse should:
*Allow the toddler to keep the blanket
Rationale: Because toddler has a "security object" such as a blanket, which helps them feel safe and secure.
Nurse should advice the parents that dental screening should begin at
* 12 - 18 months
Rationale: 12 - 18 month is the current recommended age for the first dental screening.
At what age should the nurse counsel parents that a child is capable of learning and repeating the family's telephone number?
* 5 years old
Rationale: The average 5 year old is capable of verbalizing number sequences, or repeating the telephone number.
When preparing a preschooler for a tonsillectomy, the nurse should:
* Use an anatomically correct model to demonstrate the procedure.
Rationale: The nurse should use medical play or therapeutic play to teach the child what will happen during surgery.
6 year old proudly tells the nurse that he has a loose tooth, and then ask the nurse how many of his baby teeth he is going to loose?
* 20 baby teeth
Rationale: 20 of his baby teeth or primary teeth.
A parent with Hemophilia wants to know whats the cause of their disease.
*The mother transmit the gene to his son. There is also a 50% chance that the mother will pass the traits to each of his children.
A 48 year old man with an endotracheal tube need suctioning. How should the nurse perform the procedure?
*Insert the suction catheter until resistance is met, then withdraw it slightly. Apply suction intermittently as the catheter is withdrawn.
Rationale: withdraw 0.4-0.8 in (1-2 cm), apply intermittent suction with twirling motion.
A 47 year old woman comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse knows that phobias involve.
* Projection and displacement
Rationale: Projection (attribute one's thoughts or impulse to another) and displacement (shifting of emotion concerning person or object to another neutral or less dangerous object or person)
The prenatal client at eight-weeks gestation has positive VDRL. In preparing for teaching plan, what will be the most appropriate to include:
* Instructing the client on the importance of taking the penicillin for the prescribe time.
Rationale: physical, vitally important to complete all the penicillin.
Infant with fetal alcohol syndrome. The nurse would expect to see.
* An infant with a small head circumference, low birth weight, and undeveloped cheekbones.
Rationale: Seen in fetal alcholol syndrome.
Hydromorphone hydrochloride (Diladid) side effect.
* hypotension and respiratory depression
Rationale: narcotic analgesic used for moderate to severe pain, monitor vital signs frequently
66 year old client with Insulin-dependent diabetes mellitus (IDDM). Client is unwilling to perform blood glucose monitoring, she test her urine for sugar and acetone. The nurse knows that bloods glucose monitoring is preferred over urine testing for glucose because
* the renal threshold for glucose is elevated in the elderly
Rationale: The level at which glucose starts to appear in the urine increases, leading to false-negative reading, result in elevated glucose level.
18 month old with diagnose with laryngotracheobronchitis (LTB). Initial assessment, the nurse expects to find.
* Inspiratory stridor and restlessness
Rationale: This condition is characterized by edema and inflamation of upper airways.
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