Nokea
A 5-year-old girl is having a checkup before starting kindergarten. The nurse asks her to do the "finger-to-nose" test. What is the nurse testing for?
- A. Deep tendon reflexes
- B. Cerebellar function
- C. Sensory discrimination
- D. Ability to follow directions
Correct Answer: B
Rationale: The nurse is testing the girl's cerebellar function by asking her to do the "finger-to-nose" test. The cerebellum is the part of the brain that plays a crucial role in coordinating movement, balance, and posture. In the finger-to-nose test, the child is asked to touch her own nose and then the nurse's finger repeatedly. A properly functioning cerebellum helps control and coordinate these precise movements. If there are issues with the cerebellar function, the child might have difficulty performing this task accurately, indicating a potential problem with motor coordination and balance.
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A patient complains of tingling in his fingers. He has positive Trousseau's and Chvostek's signs. He says that he feels depressed. Choose the most likely serum calcium (Ca ) value for this patient:
- A. 11mg/dl
- B. 7mg/dl
- C. 9mg/dl
- D. 5mg/dl
Correct Answer: A
Rationale: The patient's symptoms of tingling in the fingers, positive Trousseau's and Chvostek's signs, and feeling depressed are suggestive of hypocalcemia, which is commonly associated with low serum calcium levels. In this case, the most likely serum calcium value would be below the normal range, which is around 8.5-10.5 mg/dl. Among the given choices, an extremely low calcium value of 5mg/dl (Choice D) would be more consistent with severe hypocalcemia presenting with tetany and other neuromuscular symptoms rather than depression and mild symptoms. On the other hand, a high calcium level of 11mg/dl (Choice A) would indicate hypercalcemia, which can lead to neuropsychiatric symptoms like depression, as seen in this patient's presentation. Therefore, Choice A (11mg/dl) is the most likely serum calcium value for
A 13-year-old is worried because his breasts are growing and are tender. What should the nurse tell him?
- A. We will draw blood to determine the cause.
- B. It is a slight hormonal imbalance that can be corrected with medication.
- C. It is a normal condition of puberty (gynecomastia) that usually resolves within a year or two.
- D. It is a rare finding in boys during puberty.
Correct Answer: C
Rationale: Gynecomastia and breast tenderness occur in about one-third of boys during mid-puberty and usually resolve within 2 years.
The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
- A. "Client will lose 2lb per week on a calorie-restricted diet."
- B. "Client will exhibit no signs or symptoms of aspiration."
- C. "Client will exhibit bowel and bladder continence."
- D. "Client will exhibit alertness and orientation to person, place, and time."
Correct Answer: B
Rationale: Polymyositis is a condition that involves inflammation of the muscles, including the muscles involved in swallowing (dysphagia) and breathing. This can lead to a higher risk of aspiration, where food or fluids go into the airway instead of the esophagus. Therefore, monitoring for signs and symptoms of aspiration and ensuring the client exhibits no signs of aspiration are crucial in the care of a client with polymyositis. The other options are not directly related to the potential problems associated with polymyositis and are more general aspects of nursing care.
Which of the ff. positions is best for a chest drainage system when the patient is being transported by wheelchair?
- A. Hang it on the top of the wheelchair backrest.
- B. Place it on the patient's feet and ask the patient to hold it.
- C. Hang it on the same pole as the patient's IV.
- D. Place it in the patient's lap.
Correct Answer: A
Rationale: The best position for a chest drainage system when the patient is being transported by wheelchair is to hang it on the top of the wheelchair backrest (Option A). This ensures that the chest drainage system remains upright and secure during transportation. Placing it on the patient's feet and asking the patient to hold it (Option B) is not ideal as it can cause discomfort and potentially compromise the drainage system. Hanging it on the same pole as the patient's IV (Option C) may lead to entanglement and interference with the IV line. Placing it in the patient's lap (Option D) is also not recommended as it can be cumbersome and may lead to accidental dislodgement of the chest drainage system. Therefore, hanging it on the top of the wheelchair backrest provides stability and ease of transport for the patient.
Which of the following is disease process characterized by a chronic progressive inflammation of the sacroiliac and costovertebral joints and adjacent soft tissue?
- A. Rheumatoid arthritis
- B. Scoliosis
- C. Kyphosis
- D. Ankylosing spondylitis
Correct Answer: D
Rationale: Ankylosing spondylitis is a chronic inflammatory disease primarily affecting the sacroiliac joints and the spine. It leads to progressive inflammation of the sacroiliac and costovertebral joints, which can cause pain, stiffness, and eventually lead to fusion of the affected joints. This condition is also characterized by inflammation of other joints, tendons, and ligaments, as well as extra-articular manifestations such as uveitis and cardiac involvement. Ankylosing spondylitis is more common in young males and is associated with the presence of the HLA-B27 genetic marker. It is important to diagnose and manage ankylosing spondylitis early to help prevent complications and improve quality of life for affected individuals.