Nokea
A 4-year-old child has Down syndrome. The community health nurse has coordinated a special preschool program. The nurse's primary goal is to:
- A. Provide respite care for the mother
- B. Facilitate optimal development
- C. Provide a demanding and challenging educational program
- D. Prepare child to enter mainstream education
Correct Answer: B
Rationale: The primary goal for a child with Down syndrome is to facilitate optimal growth and development through tailored interventions.
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The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this finding?
- A. Palpate these pulses again in 15 minutes.
- B. Use a Doppler to determine presence and strength of these pulses.
- C. Document the finding that the pulses are not palpable.
- D. Call the physician and notify the physician of this finding.
Correct Answer: B
Rationale: Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse is present.
The nurse is caring for a client with a history of a seizure disorder who is receiving Carbamazepine (Tegretol). The nurse should monitor the client for:
- A. Leukopenia
- B. Hypotension
- C. Hyperglycemia
- D. Weight gain
Correct Answer: A
Rationale: Carbamazepine can cause leukopenia, requiring monitoring of white blood cell counts. Hypotension, hyperglycemia, and weight gain are not primary side effects.
The client is admitted with a diagnosis of abruptio placenta. Which diagnostic test is most likely to be ordered?
- A. Ultrasound
- B. Fetal heart monitoring
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Ultrasound can confirm placental separation in abruptio placenta and fetal heart monitoring assesses for distress due to hypoxia. Both tests are critical for diagnosis and management.
An elderly client is diagnosed with interstitial cystitis. Which finding differentiates interstitial cystitis from other forms of cystitis?
- A. The client is asymptomatic.
- B. The urine is free of bacteria.
- C. The urine contains blood.
- D. Males are affected more often.
Correct Answer: B
Rationale: Interstitial cystitis is characterized by chronic pelvic pain and urinary symptoms without bacterial infection, so the urine is typically free of bacteria, unlike bacterial cystitis.
The nurse is educating a group of caregivers about the West Nile virus. A participant asks, 'How can you get the West Nile virus?' The nurse explains that the virus can be transmitted by which source(s)?
- A. Mosquitoes
- B. Blood transfusions
- C. Transplanted organs
- D. Birds
- E. Horses
Correct Answer: A, B, C
Rationale: West Nile virus is transmitted by mosquitoes (A), blood transfusions (B), and organ transplants (C). Birds (D) and horses (E) are hosts but not direct vectors to humans.