The nurse is reviewing the laboratory test results of a child who is suspected of having systemic lupus erythematosus (SLE). What would the nurse identify as supporting this diagnosis? Select all that apply
A) Positive antinuclear antibody (ANA)
B) Increased C3 levels
C) Thrombocytopenia
D) Leukopenia
E) Increased hematocrit
Ans: A, C, D
Laboratory findings may include decreased hemoglobin and hematocrit, decreased platelet count, and low white blood cell count. Complement levels, C3 and C4, will also be decreased. Though not specific to SLE, the ANA is usually positive in children with SLE.
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A child experiences a respiratory arrest and is intubated. What is the best nursing assessment parameter to immediately verify proper placement of the endotracheal tube?
A) Symmetrical rise and fall of the chest B) Chest x-ray shows right bronchial intubation. C) Tidal volume is within limits for age. D) Absence of sternal retractions and grunting
The nurse is caring for a woman with a placental abruption and suspects the patient has developed disseminated intravascular coagulation (DIC). What interventions does the nurse anticipate?
A. Administering IV fibrinogen B. Performing hourly vaginal exams to assess for cervical dilation C. Performing blood pressure assessments every 4 hours D. Obtaining consent for a cesarean birth
The nurse is assessing a patient's ears. Which is a primary function of the ears that the nurse will include in the assessment process?
1) Visual assessment 2) Taste assessment 3) Smell assessment 4) Equilibrium assessment
Which of the following is an appropriately stated nursing intervention?
A) Ambulate in the hall B) Stand at bedside with assistance C) Ambulate 30 ft. twice a day with assistance of walker D) Ambulate with assistance of walker