Exam #3 Mixed

A child with increased intracranial pressure is being treated with hyperventilation. The nurse understands the need for this treatment is based on which of the following?

• PaCO2 levels decrease, causing vasoconstriction.

• Drainage of cerebrospinal fluid occurs.

• Activity is controlled via a stimulator.

• Hyperexcitability of the nerves is reduced.

A patient has been diagnosed with hypoparathyroidism following a thyroidectomy. What medications should the nurse anticipate in order to prevent further complications? Select all that apply.

• Combo of Ca+, magnesium, & vitamin D3

• Loop diuretic

• IV calcium gluconate

• Sedatives

• Aluminum hydroxide gel or aluminum carbonate

A 4-year-old child is brought into the ER after reportedly falling off his bicycle. X-rays show he has a spiral fractal in his left humerus & evidence of old fractures in his other extremities. The nurse suspects the child may be a victim of child abuse. Which of the following actions should the nurse take to protect the patient? Select all that apply.

• Provide safety for the child & report the findings within 48 hours, ensuring follow-up

• Use anatomical terms which may be more familiar to the child & tell the child the abuse was not their fault

• Stay with the patient & provide direct observation even when parents are present

• Providing coping for the family in terms of parenting classes, realistic expectations, & Parents Anonymous

• Understand that pneumonia may be a complication of abuse

The nurse is caring for a 13-year-old girl with delayed puberty. Based on the nurse's knowledge of this condition, the nurse would include which nursing diagnosis in the child's plan of care?

• Disabled family coping related to the child's disorder

• Imbalanced nutrition, less than body requirements related to the child's short stature

• Noncompliance related to the need for lifelong hormone therapy

• Deficient knowledge related to the administration of estradiol

You are an RN in the ICU and hear a high pressure alarm coming from an intubated patient. The monitor shows increased PIP, PaO2 75, & PaCO2 49. Upon assessment, the patient is displaying decreased breath sounds & unequal chest excursion. What priority intervention should occur next?

• Call a code & stay with the patient

• Call the physician & prepare for chest tube insertion

• Perform manual ventilation with an ambu bag

• Turn down vent settings & call the physician

• Disconnect the patient from the vent

Name 6 non-modifiable & modifiable factors the nurse would instruct the patient about concerning atherosclerosis (3 factors each).

The nurse is providing care to a child with a long-leg hip spica cast. Which of the following would be a priority nursing diagnosis?

• Risk for impaired skin integrity due to cast and location

• Deficient knowledge related to cast care

• Risk for delayed development related to immobility

• Self-care deficit related to immobility

A patient comes into the ER with complaints of GI pain, back & joint pain, & complains of chronic constipation. Patient also has a history of psychological disturbances over the past year. Abdominal x-rays are taken & kidney stones are shown on the left side. What does the nurse expect the lab results to look like? Select all that apply.

• Serum Ca+ > 10

• Increased PTH

• Decreased serum phosphate

• Serum Ca+ > 13

• Increased serum phosphate

Two parents bring in their 17-year-old son who is presenting with an altered LOC & discoloration of the skin. The parents report he had suffered from what seemed like a stomach bug a few days earlier, which he recovered from. However, they state that earlier that day he began to complain of pain in the RUQ & was becoming unresponsive to stimuli. The nurse should anticipate all of the following actions except?

• Administer N-acetylcysteine IV over 3 days

• Administer activated charcoal either through an NGT or opaque container

• Assess for an eating disorder

• Assess for disruptive behavior disorders

• Administer naloxone

The nurse is assessing an infant and notes that the infant's urine has a mousy odor. Which of the following orders would the nurse suspect?

• Amoxicillin for 7-10 days

• Special formula with low-phenylalanine

• GnRH SQ daily

• Insulin-sensitizing meds