Nokea
A 9-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of Syndeham's chorea?
- A. Irregular movements of the arms and legs and facial grimacing
- B. Painless swellings over the surface of the joints
- C. Faint areas of red demarcation over the back
- D. Swelling and inflammation of the joints
Correct Answer: A
Rationale: Syndeham's chorea is characterized by irregular, involuntary movements and facial grimacing, so A is correct. Answers B, C, and D describe other rheumatic fever symptoms but not chorea.
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The nurse manager has a nurse employee who is suspected of a problem with chemical dependency. Which intervention would be the best approach by the nurse manager?
- A. Confront the nurse about the suspicions in a private meeting
- B. Schedule a staff conference, without the nurse present, to collect information
- C. Consult the human resources department about the issue and needed actions
- D. Counsel the employee to resign to avoid investigation
Correct Answer: C
Rationale: Consult the human resources department about the issue and needed actions. To avoid legal repercussions, the nurse needs to consult with the human resources department for proper procedure for documentation, counseling and available resources.
Which of these parents' comments about a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?
- A. I noticed a little lump a little above the belly button.
- B. The baby seems hungry all the time.
- C. Mild vomiting turned into vomiting that shot across the room.
- D. We notice irritation and spitting up immediately after feedings.
Correct Answer: C
Rationale: Mild vomiting turned into vomiting that shot across the room. Projectile vomiting is a hallmark of pyloric stenosis.
Which of the following laboratory results would suggest to the emergency room nurse that a client admitted after a severe motor vehicle crash is in acidosis?
- A. Hemoglobin 15 gm/dl
- B. Chloride 100 mEq/L
- C. Sodium 130 mEq/L
- D. Carbon dioxide 20 mEq/L
Correct Answer: D
Rationale: Serum carbon dioxide is an indicator of acid-base status. This finding would indicate acidosis.
The licensed practical nurse is caring for a 1-year old with a history of prematurity. Which developmental finding requires further evaluation by the physician?
- A. The child has been creeping for 3 months.
- B. The child can pull to a standing position.
- C. The child uses a pincer grasp.
- D. The child can sit with support.
Correct Answer: D
Rationale: Sitting with support at 1 year is delayed, especially for a preterm child, and requires evaluation. Creeping , standing , and pincer grasp are age-appropriate.
The nurse enters an adult's room to premedicate for surgery. The client says, 'You know, nurse, that form I signed said something about a nephrectomy. What does that mean?' How should the nurse respond initially?
- A. What did your surgeon explain to you about your operation?'
- B. Don't worry about the technical terms. We'll take good care of you.'
- C. I think you're just nervous about the surgery. This injection will make you feel calmer.'
- D. It is a kidney operation.'
Correct Answer: A
Rationale: Asking what the surgeon explained clarifies the client's understanding, ensuring informed consent and addressing concerns.