The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?
Ear pain and fever.
Elevated WBC and sedimentation rate.
Increased BUN and serum creatinine.
Positive Epstein-Barr, and malaise.
The Correct Answer is D
Rationale
A. Ear pain is not typically a common symptom of mononucleosis. Fever, however, is commonly seen in mononucleosis due to the body's immune response to the viral infection.
B. In mononucleosis, there is often an increase in white blood cells (specifically lymphocytes) and an elevated sedimentation rate (ESR). These changes reflect the body's immune response to the Epstein- Barr virus infection.
C. Increased blood urea nitrogen (BUN) and serum creatinine levels are not typically associated with mononucleosis. These markers are more indicative of kidney function and are not directly affected by the viral infection causing mononucleosis.
D. A positive test for Epstein-Barr virus (EBV) antibodies is diagnostic for mononucleosis. Malaise, which is a general feeling of discomfort or illness, is a hallmark symptom of mononucleosis along with other systemic symptoms like fatigue, sore throat, swollen lymph nodes, and sometimes a rash.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
A. Perform pulmonary function test
This is important for assessing lung function, but it is not an immediate priority during an acute exacerbation when the patient's oxygen saturation is low and they are experiencing respiratory distress.
Pulmonary function testing can be done once the patient's acute symptoms are stabilized.
B. Measure vital signs
While vital signs are important for ongoing assessment, the patient's vital signs were already assessed at admission and are being monitored every 4 hours as per orders.
Administering oxygen and albuterol to stabilize the patient's condition takes precedence over routine vital sign checks immediately after the initial assessment.
C. Provide a regular diet tray
This is a routine aspect of care and does not address the acute respiratory distress or hypoxemia that require immediate attention.
It can be done once the patient's respiratory status has stabilized.
D. Give albuterol as ordered
The patient is experiencing an asthma exacerbation with wheezing and subcostal retractions. Albuterol is a bronchodilator that helps relieve bronchospasm and improve airflow.
It was ordered for nebulization now and every 4 hours PRN (as needed) for wheezing.
Administering albuterol promptly is crucial to help alleviate respiratory distress and improve lung function.
E. Apply oxygen 1 L/minute
The patient's oxygen saturation is 91% on room air, which is below the target of greater than 94%. Oxygen therapy is indicated to correct hypoxemia and improve oxygen saturation.
The order specifies to titrate oxygen to keep saturation greater than 94%, starting at 1 L/minute via nasal cannula.
Correct Answer is A
Explanation
Rationale
A. In the early phase following a burn injury, there is increased capillary permeability due to the release of inflammatory mediators. This results in fluid shifting from the intravascular space into the interstitial space (capillary leaking), leading to hypovolemia and decreased tissue perfusion. Administering crystalloid fluids helps to restore intravascular volume (fluid resuscitation) and improve tissue perfusion.
B. Burn injuries can lead to increased evaporative water loss through damaged skin (insensible water loss). Crystalloid fluids help to replace this lost fluid and maintain adequate hydration status in the client.
C. In severe burn injuries, there may be a need for blood transfusions due to hemorrhage or ongoing blood loss. Crystalloid fluids can help to extend plasma volume temporarily until blood products are available for transfusion, thereby supporting circulatory stability.
D. Burn injuries can disrupt electrolyte balance due to fluid shifts and tissue damage. Crystalloid fluids contain electrolytes (such as sodium and chloride) that help to restore and maintain electrolyte balance in the body.
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