Nokea
A child has been seen by the school nurse for dizziness since the start of the school term. It happens when standing in line for recess and homeroom. The child now reports that she would rather sit and watch her friends play hopscotch because she cannot count out loud and jump at the same time. When the nurse asks her if her chest ever hurts, she says yes. Based on this history, the nurse suspects that she has:
- A. Ventricular septal defect (VSD)
- B. Aortic stenosis (AS)
- C. Mitral valve prolapse
- D. Tricuspid atresia
Correct Answer: B
Rationale: AS can progress and result in exercise intolerance, which may improve with rest.
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An older female client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. To determine if the client is experiencing any long-term complication of DM, which assessments should the nurse obtain?
- A. Serum creatinine and blood urea nitrogen (BUN)
- B. Sensation in feet and legs
- C. Skin condition of lower extremities
- D. Visual acuity
Correct Answer: B
Rationale: These assessments are crucial for detecting complications such as neuropathy, nephropathy, and retinopathy.
Down syndrome and VSD
- A. Doesn't close spontaneously as in children without downs
- B. Inaudible murmur is a characteristic feature / Murmur is not audible
- C. Pulmonary Hypertension is a late complication
- D. If no murmur, condition need not be investigated
Correct Answer: C
Rationale: Pulmonary hypertension is a known late complication in Down syndrome with VSD.
An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary stream, and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement?
- A. Collect a urine specimen for culture analysis
- B. Review the client's fluid intake prior to bedtime
- C. Palpate the bladder above the symphysis pubis
- D. Obtain a fingerstick blood glucose level
Correct Answer: C
Rationale: Palpating the bladder helps assess for urinary retention, which is common in older males with prostate issues.
A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?
- A. Obtain oxygen saturation level
- B. Encourage incentive spirometry
- C. Assess lower extremity circulation
- D. Administer PRN oral antipyretic
Correct Answer: D
Rationale: Administering an antipyretic addresses the fever, which is a priority in this client to prevent further complications.
Hypertrophic obstructive cardiomyopathy
- A. Causes LV outflow tract obstruction
- B. Occurs after adenoviral infection
- C. Commonly occurs in infancy
- D. Double apical impulse
Correct Answer: A
Rationale: Hypertrophic obstructive cardiomyopathy primarily causes left ventricular outflow tract obstruction.