For correct answer choice:

Use simple words and short phrases when speaking to him. is correct. After a left-sided CVA, a client may experience difficulty with language comprehension (receptive aphasia). Using simple, concise language helps the client better understand instructions.

For incorrect answer choices:

Speak louder to make sure he can hear and process instructions. is incorrect. Speaking louder is not helpful in aphasia. The issue is with language processing, not hearing. Yelling or speaking loudly can increase frustration.

Avoid using gestures to prevent confusing him. is incorrect. Gestures and non-verbal cues can be helpful in communicating with someone who has aphasia because they provide visual reinforcement for verbal instructions.

Provide written instructions as an alternative to verbal communication. is incorrect. Written communication may not be effective for a client with receptive aphasia, as language comprehension is impaired. Verbal communication, supplemented by gestures, is more effective.

For correct answer choice:

Bulging anterior fontanel is correct. In infants and young children, a bulging anterior fontanel (soft spot on the head) is a key sign of increased intracranial pressure. This is particularly concerning because the skull is still forming, and a rise in pressure can cause permanent brain damage if not addressed immediately.

For incorrect answer choices:

Sleeping during nap time is incorrect. A child taking a nap at an appropriate time of day is expected behavior and does not indicate increased ICP unless the child is excessively difficult to rouse or excessively sleepy.

Occasional crying spells is incorrect. Occasional crying may be normal, especially after a traumatic event. It is not a direct indicator of increased ICP unless it becomes persistent or high-pitched.

Complaints of a mild headache is incorrect. While a headache can be a symptom of increased ICP, a mild headache by itself is not as urgent a finding as a bulging fontanel. The nurse should monitor the child but does not need to report this symptom immediately unless it worsens.

For correct answer choice:

Neisseria gonorrhoeae is correct. Neisseria gonorrhoeae, the bacterium that causes gonorrhea, is a common cause of pelvic inflammatory disease (PID). It can ascend from the lower genital tract to the upper reproductive organs, leading to inflammation, scarring, and complications such as infertility.

For incorrect answer choices:

Staphylococcus aureus is incorrect. Staphylococcus aureus is associated with skin and soft tissue infections, such as cellulitis and toxic shock syndrome, but it is not a common cause of PID.

Escherichia coli is incorrect. While E. coli can cause UTIs and is associated with gastrointestinal infections, it is not typically involved in PID.

Candida albicans is incorrect. Candida albicans is a yeast that causes candidiasis (vaginal yeast infections) but does not cause PID. It typically results in localized infections without involving the upper genital tract.

For correct answer choice:

All are correct. Jaundice occurs when there is elevated bilirubin deposition in the skin; elevated unconjugated bilirubin can be neurotoxic. Left untreated in newborns, acute or chronic encephalopathy may occur, which could result in hearing loss, seizures, and cerebral palsy.

For incorrect answer choices:

LEARNING OBJECTIVE
Understanding the pathophysiology of the newborn's jaundice, presentation, and treatment is critical in the preparation of parents. Parents must recognize when they need to seek treatment to prevent complications.

For correct answer choice:

Prepare the child for X-ray of the upper airways is correct. The child’s symptoms are indicative of epiglottitis, and an urgent lateral neck X-ray can confirm the diagnosis. This is essential to assess the severity of airway obstruction and guide further treatment.

For incorrect answer choices:

Suction the child’s airway is incorrect. Suctioning may cause increased irritation and lead to further airway obstruction in a child with suspected epiglottitis. The focus should be on maintaining the airway.

Administer acetaminophen for the fever is incorrect. While fever management is important, the priority here is securing the airway, as epiglottitis can rapidly progress to life-threatening respiratory obstruction.

Perform a complete respiratory assessment is incorrect. Although monitoring respiratory status is important, it is not the priority intervention at this moment. The child’s airway needs to be urgently assessed and stabilized.

For correct answer choice:

Left costovertebral angle is correct. Pain in the costovertebral angle (CVA) is a classic sign of renal involvement, often indicating conditions such as kidney infection known as pyelonephritis or other renal issues. This is the appropriate area to assess for discomfort when determining if urinary symptoms are renal in origin.

For incorrect answer choices:

Suprapubic region is incorrect. Pain in the suprapubic area is generally associated with bladder issues, such as cystitis (bladder infection), and does not indicate renal problems.

Perineal area is incorrect. The perineal area is more commonly related to infections of the external genitalia or urinary meatus and is not indicative of kidney issues.

Bladder is incorrect. Bladder pain typically points to a lower urinary tract issue, such as a UTI, and does not reflect renal pathology.

For correct answer choice:

Before suctioning begins, the patient should receive 100% oxygen (hyperoxygenation). Less than 15 seconds should occur during each pass(a). The patient should be allowed to recover between each pass of the catheter.

For incorrect answer choices:

There has been no reduction in ventilator-associated pneumonia since the introduction of in-line suction catheters. The American Association of Respiratory Care does not recommend the routine use of saline.

LEARNING OBJECTIVE
Knowledge of each procedure’s details is essential to prevent complications. Trauma can occur from suctioning, and the patient may be exposed to a possible source of infection.

For correct answer choice:

Repeated episodes of vomiting is correct. Vomiting, especially without nausea, is a concerning sign of increased intracranial pressure (ICP), particularly after head trauma. It can occur due to pressure on the brain's vomiting center in the medulla oblongata.

For incorrect answer choices:

Clear nasal drainage is incorrect. While this might suggest a cerebrospinal fluid (CSF) leak (requiring further investigation), it’s not as immediately concerning for increased ICP as repeated vomiting.

Complaints of a headache is incorrect. While a headache is common after head trauma, it’s not as definitive for increased ICP as repeated vomiting.

Ability to answer simple questions is incorrect. The ability to answer questions suggests that the child is alert and oriented, which is a good sign. Difficulty in answering questions or confusion would be more concerning.

For correct answer choice:

While calling for help, the airway should be cleared(suctioned), and rescue breathing should start as the patient is already blue. The pulse should be checked; if absent, compressions should also be started.

For incorrect answer choices:

LEARNING OBJECTIVE
Knowledge of the patient's history and emergency procedures is critical to timely response and expedited care. Given the aspirate, skin color blue, and history of seizure, it is likely the patient aspirated his food when he had a seizure and hence stopped breathing. Emergency procedures start with a=airway.

For correct answer choice:

If the transducer is placed too high, the reading will be abnormally low. Hence, if placed too low, the reading will be abnormally high. The transducer is to be positioned at the right atrium.

For incorrect answer choices:

All ventilator patients should have an arterial catheter for blood gas monitoring. False arterial cannulation is not routine patient care; some patients may have contraindications.

In the United States, catheter-related bloodstream infections are estimated at 200,000 annually. Currently, there are about 80,000 catheter-related bloodstream infections annually, not 200,000.

LEARNING OBJECTIVE
Nurses should be prepared to care for catheters and understand their positioning. Knowledge of inappropriate positioning effects is crucial as well. The rationale for use must be reviewed daily to limit the risk of complications on all invasive lines, catheters, drains, devices, etc., to prevent hospital-acquired infections.

For correct answer choice:

The tumor has extended beyond the kidney but remains completely resectable is correct. This statement is correct for stage II Wilms tumor, where the tumor has extended beyond the kidney but can still be completely removed surgically.

For incorrect answer choices:

The tumor has not invaded surrounding structures and is less than 3 cm in size is incorrect. This describes stage I Wilms tumor and is not applicable to stage II.

The tumor is confined to the kidney with evidence of lymph node involvement is incorrect. This statement would indicate a stage III classification, not stage II.

The tumor has spread into the abdominal cavity and is unresectable is incorrect. This describes stage IV Wilms tumor, where the tumor has metastasized and cannot be surgically removed.

For correct answer choice:

Dopamine is correct. In Parkinson’s disease, dopamine-producing neurons in the brain degenerate, leading to impaired motor function. This deficiency makes it difficult for patients to perform fine motor tasks, like buttoning a shirt, writing, or tying shoelaces.

For incorrect answer choices:

GABA is incorrect. GABA (gamma-aminobutyric acid) is an inhibitory neurotransmitter that helps regulate nervous system activity but is not the primary neurotransmitter associated with Parkinson's disease symptoms.

Norepinephrine is incorrect. Norepinephrine is involved in the body’s response to stress and helps regulate blood pressure and alertness. While it may be secondarily affected in Parkinson's disease, it is not the primary cause of the motor symptoms.

Serotonin is incorrect. Serotonin affects mood, sleep, and appetite, but it is not directly involved in the control of motor movements, which is the main issue in Parkinson’s disease.

For correct answer choice:

Cheyne-Stokes respiration is correct. It describes the observed pattern of alternating periods of increasing and decreasing respiratory depth and rate which includes the episodes of apnea. These are frequently noted in patients with severe brain injuries or neurological deficits.

For incorrect answer choices:

Ataxic breathing is incorrect. This is characterized by irregular breathing patterns with varying depths and periods of apnea but lacks the cyclical depth changes of Cheyne-Stokes respiration.

Tachypnea with hyperventilation is incorrect. This condition involves rapid and deep breathing but does not include the cyclical nature of increasing and decreasing depths along with periods of apnea.

Hypoventilation with shallow breathing is incorrect. This refers to a reduced rate and depth of breathing without the alternating pattern and apnea characteristic of Cheyne-Stokes respiration.

For correct answer choice:

Hypoglycemia is correct. The patient’s cold, clammy skin, nausea, dizziness, and shaking are classic signs of hypoglycemia. Postoperative stress, limited food intake, and the use of insulin or oral hypoglycemics in diabetes patients increase the risk of hypoglycemia.

For incorrect answer choices:

Hyperglycemia is incorrect. Hyperglycemia typically presents with symptoms like excessive thirst, frequent urination, and blurred vision rather than cold, clammy skin or shaking.

Postoperative infection is incorrect. Although the infection can cause nausea and dizziness, the specific symptoms of cold, clammy skin and shakiness suggest a more immediate problem related to blood sugar control, which points to hypoglycemia.

Fluid volume deficit is incorrect. While fluid volume deficits can cause dizziness, they are more likely to be associated with dry skin and mucous membranes, tachycardia, and hypotension. The cold, clammy skin is more indicative of hypoglycemia.

For correct answer choice:

Crackles in the lungs upon auscultation is correct. Crackles (rales) are heard when fluid accumulates in the alveoli, which is a typical finding in pulmonary edema. This fluid impairs gas exchange and leads to respiratory distress.

For incorrect answer choices:

Low oxygen saturation with normal respiratory rate is incorrect. Pulmonary edema typically presents with both low oxygen saturation and a rapid respiratory rate (tachypnea) due to the body’s attempt to increase oxygen intake.

Bradycardia and hypotension is incorrect. Patients with pulmonary edema often experience tachycardia, as the body compensates for low oxygen levels by increasing heart rate. Hypotension may occur later, but tachycardia is a more common early sign.

Clear lung sounds and diminished breath sounds is incorrect. Pulmonary edema is marked by abnormal lung sounds such as crackles or wheezing. Clear lung sounds are inconsistent with fluid accumulation in the lungs.

For correct answer choice:

Hydrocolloid dressings are effective for minor burns. They facilitate healing by forming a protective layer over the wound and promoting a moist environment. They are also effective for early-stage pressure ulcers and superficial wounds.

For incorrect answer choices:

Dressings with foam can be used on various wounds with moderate to heavy exudate. They promote healing by absorbing excess fluid, maintaining a moist environment, and minimizing the risk of maceration to surrounding tissue.

Alginate dressings benefit wounds with a large amount of exudate. They are derived from seaweed and become gel once in contact with wound fluid, absorbing the drainage. They are ideal for necrotic tissue and wounds with slough. They should not be utilized in dry wounds or those with minimal exudate.

Gauze dressings are dry and should not be placed on burns, which need to be kept moist. Once primary dressings, they are used as secondary dressings because they adhere to the wound surface and cannot attain a moist environment.

LEARNING OBJECTIVE
Best practices for wound care are an essential part of nursing. The wound must be assessed before decisions can be made on dressing type. As a nurse, assessment skills are critical in the decision-making process.