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Nurs. 128 Brittany Long Core Vsims Pre & Post Questions with correct answers
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Nurs. 128 Brittany Long Core Vsims Pre & Post Questions with correct answers
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Nurs. 128 Brittany Long Core Vsims Pre & PostQuestions with correct answers
A 5-year-old with a history of sickle cell anemia presents to the
emergency room with acute leg pain. When obtaining the health history,
the nurse should include questions related to which factor(s)? (Select all
that apply.)
A) Frequency of vaso-occlusive crises
B) Precipitating events
C) Past hospitalizations and treatment
D) Family history of blood transfusions
E) Immunization history Correct Answer-A) Frequency of vaso-
occlusive crises
B) Precipitating events
C) Past hospitalizations and treatment
E) Immunization history
Rationale: When obtaining a health history on a patient with sickle cell
anemia, the nurse should elicit information related to growth and
development, frequency and extent of vaso-occlusive crises, past
hospitalizations and treatment for pain crises, immunization history,
personal history of blood transfusions, current medication regimen, and
precipitating events. A family history of blood transfusions would not be
relevant, as it would not affect the patient.
The nurse is performing a physical assessment on a 5-year-old patient.
Which statement demonstrates that the nurse understands
developmentally appropriate communication?
, A) "I want to listen to you breathe. I need you to help me hold my
stethoscope in place."
B) "I am going to take your temperature and blood pressure now."
C) "You need to change into a hospital gown before I can examine you."
D) "Your parent will need to wait outside while I complete your
assessment." Correct Answer-A) I want to listen to you breathe. I need
you to help me hold my stethoscope in place.
Rationale: Preschoolers should be given a job during the assessment
process, such as holding the stethoscope or pen light. The nurse should
avoid using confusing terms such as temperature, blood pressure, or test.
Instead, the nurse should say, "Let's see how warm you are" or "I want
to listen to you breathe." When assessing a preschool-aged patient, the
patient can sit in the caregiver's lap or sit on the exam table within reach
and eye contact of the caregiver. Children should never be forced to
change into a gown. It is important to allow children to stay in their own
clothing and to wear shorts or underwear under a gown if preferred.
The nurse is caring for a patient weighing 16 kg with an order to
administer acetaminophen (Tylenol) for acute pain crisis. The safe
dosage range for children is 10 to 15 mg/kg/dose. What is the maximum
safe dose for this patient in milligrams? __________ Correct Answer-
240 mg
Rationale: To determine the maximum safe dose for this patient,
multiply the high end of the dosage range by the patient's weight in
kilograms: 15 × 16 = 240. Thus, the maximum safe dose is 240 mg.
A nurse is explaining the pathophysiology of vaso-occlusive pain crisis
to the caregiver of a patient with sickle cell anemia. Which explanation
by the nurse is correct?
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