Steve is diagnosed with celiac disease and experiences celiac crisis secondary to upper respiratory tract infection; which of the following would Nurse Nancy expect to assess?

Correct Answer: A

Rationale: In a celiac crisis, which is a severe form of reaction to gluten ingestion in individuals with celiac disease, symptoms can include severe diarrhea, vomiting, dehydration, electrolyte imbalances, and lethargy. The upper respiratory tract infection adds an additional stressor to the body, further worsening the symptoms. Lethargy is often seen in such cases due to the body's reaction to the illness and malabsorption of nutrients caused by celiac disease. While weight loss is common in celiac disease due to malabsorption, weight gain is unlikely in a celiac crisis. Respiratory distress is not a typical symptom directly related to celiac disease or its crisis. Watery diarrhea can be a common symptom of celiac disease, but specific to the question, lethargy would be the most expected assessment finding in Steve's case.

Correct Answer: A

Rationale: Pain management is a crucial component in the plan of care for a preschool-age child admitted with a vasoocclusive sickle cell crisis. Sickle cell disease causes blood vessels to become blocked, leading to ischemia and pain. Managing pain promptly and effectively is necessary to improve the child's comfort level and prevent complications. Pain management strategies typically involve the use of analgesic medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids, tailored to the child's age and weight. Additionally, non-pharmacological interventions like distraction techniques and positioning can help in reducing pain and promoting relaxation in children during a sickle cell crisis.

Correct Answer: C

Rationale: Ventricular hypertrophy of endocarditis is a cardiac condition resulting from inflammation and infection of the endocardium along with hypertrophy of the ventricular walls. It requires specific treatment with appropriate antibiotics to manage the infection and inflammation. TOF (Tetralogy of Fallot) is a cyanotic heart defect characterized by four specific heart abnormalities (pulmonary valve stenosis, overriding aorta, VSD, and right ventricular hypertrophy). The question asks for an example of an acyanotic heart defect, where blood can flow through the heart without mixing poorly oxygenated and well-oxygenated blood. PDA (Patent Ductus Arteriosus), ASD (Atrial Septal Defect), and VSD (Ventricular Septal Defect) are all examples of acyanotic heart defects as they do not cause a mixing of oxygenated and deoxygenated blood.

Correct Answer: B

Rationale: Neonatal nurses are likely to use Pavlik's maneuver to detect developmental dysplasia of the hip (DDH) in newborns. Pavlik's maneuver is a technique used to diagnose, treat, and manage DDH in infants. It involves positioning the infant's hips in a flexed and abducted position to help stabilize the hip joint and promote proper development. This technique is gentle and non-invasive, making it suitable for screening infants for hip dysplasia. Other maneuvers listed, such as Barlow's, Gower's, and Allis's maneuvers, are different techniques used to assess hip stability or alignment and are not specific to DDH screening in newborns.

Correct Answer: A

Rationale: The bronchospasm and dyspnea seen in organophosphorus poisoning are primarily caused by the muscarinic action of the toxic substance. Organophosphates inhibit acetylcholinesterase, leading to an excess of acetylcholine at the neuromuscular junctions. This results in overstimulation of muscarinic receptors, causing symptoms such as bronchoconstriction, increased secretions, and respiratory distress. Nicotinic actions primarily lead to muscle weakness and paralysis, while CNS actions can cause seizures and altered mental status. So, in the case of bronchospasm and dyspnea, the muscarinic action is the main contributing factor.