A factory worker suffered a chemical burn to the eye and arrives at the Emergency department. What is the first action of the nurse?

Correct Answer: D

Rationale: The first action should be to flush the eye continuously with a sterile solution to remove the chemical and prevent further damage to the eye. This is important in cases of chemical burns to prevent the chemical from causing more harm or spreading to other parts of the eye. It is crucial to start immediate irrigation to promote the best possible outcome and help alleviate the pain and potential long-term damage. Once the eye has been thoroughly flushed, further assessment and appropriate treatment can be provided by the healthcare team.

Correct Answer: A

Rationale: Clients with diabetes insipidus lack antidiuretic hormone (ADH), also known as vasopressin. ADH plays a crucial role in regulating the amount of water reabsorbed by the kidneys, thus maintaining the body's water balance. In diabetes insipidus, there is a deficiency or decreased response to ADH, leading to excessive urine production and consequent dehydration if not managed properly. Therefore, understanding the role and function of ADH is essential for the nurse to include in the teaching plan for a client diagnosed with diabetes insipidus.

Correct Answer: A

Rationale: In the context of pharmacology and pediatric care, understanding the significance of Chvostek's sign and Trousseau's sign post-thyroidectomy surgery is crucial. These signs are indicative of hypocalcemia, which is characterized by low levels of calcium in the blood. Chvostek's sign is elicited by tapping the facial nerve in the region of the parotid gland, resulting in facial muscle twitching. Trousseau's sign involves inflating a blood pressure cuff on the arm, leading to carpal spasm. Both signs suggest neuromuscular irritability, which is a classic manifestation of low calcium levels. Option A, hypocalcemia, is the correct answer because Chvostek's and Trousseau's signs are specific to this condition. Hypokalemia (Option B) is characterized by low potassium levels, while hypercalcemia (Option C) is the opposite of what these signs indicate. Hyperkalemia (Option D) refers to elevated potassium levels and is not related to the signs mentioned. Educationally, by understanding the association between these signs and hypocalcemia, nurses and healthcare providers can promptly recognize and intervene in cases of post-thyroidectomy hypocalcemia, thereby preventing potential complications such as tetany or seizures in pediatric patients. This knowledge underscores the importance of thorough assessment and monitoring in the postoperative period, enhancing patient safety and outcomes.

Correct Answer: A

Rationale: Successful treatment of diabetes insipidus is indicated when the patient's excessive urination (polyuria) and thirst (polydipsia) are controlled. One of the primary goals of treatment is to achieve fluid balance by reducing urine output and, consequently, decreasing the excessive thirst. When the fluid intake is less than 2,500mL, it suggests that the patient's excessive thirst has decreased, indicating successful management of the condition. Monitoring and managing fluid intake are crucial in the treatment of diabetes insipidus to prevent dehydration and electrolyte imbalances. A lower fluid intake is a positive indicator that the treatment is effectively addressing the increased urine output characteristic of diabetes insipidus.

Correct Answer: A

Rationale: In pediatrics, when a baby falls off a bed, it is crucial for the nurse to monitor for signs and symptoms of potential injuries. Option A is correct because a change in level of consciousness indicates neurological involvement, tachypnea suggests respiratory distress, tachycardia may indicate shock, and petechiae can be a sign of internal bleeding or trauma. Option B is incorrect because chest pain, diaphoresis, and nausea/vomiting are more commonly associated with cardiac or gastrointestinal issues, not necessarily related to a fall. Option C is incorrect as loss of consciousness, bradycardia, and severe leg pain are not typical signs following a fall off a bed, and petechiae would be more concerning for bleeding disorders. Option D is incorrect as bradycardia, chest pain, and oliguria are not typically associated with a fall in this context but may indicate other issues like cardiac problems or renal dysfunction. Educationally, understanding the rationale behind monitoring specific signs and symptoms post-fall is crucial for pediatric nurses to promptly identify and address any potential injuries or complications that may arise, ensuring the best possible outcomes for the child.