A pediatric home care nurse schedules a visit to the home of a 4-week-old newborn who had a low thyroxine (T4) and a high thyroid stimulating hormone (TSH) at birth, and was diagnosed with congenital hypothyroidism or cretinism. Which instruction is most important for the nurse to provide the parents of this child?

Offer a low sodium formula between breast feedings.

Stimulate the infant during feedings to ensure adequate intake.

Administer supplemental thyroid hormone daily.

Monitor the infant's daily intake and weekly weight.

Answer and Explanation

The Correct Answer is C

A. Offer a low sodium formula between breast feedings. Congenital hypothyroidism is not managed with dietary sodium restrictions. The priority is thyroid hormone replacement, not sodium intake adjustments.
B. Stimulate the infant during feedings to ensure adequate intake. Infants with congenital hypothyroidism may have poor feeding due to lethargy, but stimulation during feedings is not the primary intervention. The most critical aspect of care is thyroid hormone replacement to support normal growth and brain development.
C. Administer supplemental thyroid hormone daily. Lifelong thyroid hormone replacement with levothyroxine is essential to prevent intellectual disability and growth delays. Early and consistent treatment ensures normal neurological and physical development. Missing doses or delaying treatment can result in irreversible cognitive impairment.
D. Monitor the infant's daily intake and weekly weight. While monitoring growth and nutrition is important, it is secondary to ensuring proper thyroid hormone therapy, which directly affects metabolism, weight gain, and developmental outcomes.

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Correct Answer is A

Explanation

A. Staphylococcus aureus abscess around a hair follicle. A furuncle, or boil, is a deep infection of a hair follicle caused by Staphylococcus aureus. It presents as a painful, pus-filled nodule due to bacterial invasion and inflammation. Poor hygiene, friction, or immune suppression can increase susceptibility.
B. Insect or spider bite that becomes infected. While insect bites can introduce bacteria into the skin, they do not directly cause furuncles. Secondary infection may occur, but furuncles specifically arise from infected hair follicles, not bites.
C. Sexual contact with an infected partner. Furuncles are not sexually transmitted infections. While skin-to-skin contact can spread Staphylococcus aureus, furuncles are not a direct result of sexual activity.
D. Inadequate blood supply to the area. Poor circulation can impair wound healing and increase infection risk, but furuncles result from bacterial infection of a hair follicle rather than ischemia.

A. Peripheral neurovascular dysfunction. B. Impaired skin integrity. C. Fluid volume excess. D. Acute pain and anxiety.

Correct Answer is B

Explanation

A. Peripheral neurovascular dysfunction. While some chemotherapy agents can cause neuropathy, the immediate risk of a vesicant (a drug that can cause severe tissue damage if it leaks) is extravasation, leading to skin and tissue damage, rather than direct neurovascular impairment.
B. Impaired skin integrity. Vesicants can cause severe tissue necrosis if they extravasate (leak into surrounding tissues). Leaving an IV in place for 72 hours increases the risk of infiltration or extravasation, which can lead to serious complications, including blistering, necrosis, and deep tissue injury. Proper IV site rotation and monitoring are essential to prevent skin and tissue damage.
C. Fluid volume excess. Fluid volume excess is not a direct risk related to vesicant chemotherapy. While some IV fluids can contribute to fluid overload, the primary concern with vesicants is extravasation and tissue damage.
D. Acute pain and anxiety. While pain and anxiety can occur if extravasation happens, the greatest clinical risk is the physical damage caused by tissue necrosis. Pain is a symptom of extravasation, but preventing skin and tissue injury is the priority.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client's skin and notices a raised nodule on the right forearm that is tender and filled with purulent secretions. The healthcare provider diagnosed the abscess as a furuncle. Which pathological etiology places the client at risk for the development of a furuncle?

Correct Answer is A

Explanation

A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. Which is the greatest clinical risk related to this situation?

Correct Answer is B

Explanation

Exhibits Choose the most likely options for the information missing from the statement below by selecting from the lists of options provided. The nurse recognizes that a diagnosis of dropdownbe explained by assessment findings of dropdownanddropdown

The nurse is talking with a couple at a community health fair who ask how cancerous tumors occur. Which pathophysiological process supports the nurse's reponse about cancer cells developement?

The nurse is conducting a nutritional class on foods that have been linked to help decrease the development of some forms of cancer. Which meal selection is the best choice to help reduce the risk of some cancers?

The nurse identifies the hospitalized client in which situation as being at highest risk for the development of a healthcare associated infection (HAI)?

Exhibits Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.