Nokea
A child is admitted to the hospital with a suspected diagnosis of von Willebrand's disease. On assessment of the child, which symptom would most likely be noted?
- A. Hematuria
- B. Presence of hematomas
- C. Presence of hemarthrosis
- D. Bleeding from the mucous membranes
Correct Answer: D
Rationale: The primary clinical manifestations of von Willebrand's disease are bruising and mucous membrane bleeding from the nose, mouth, and gastrointestinal tract. Prolonged bleeding after trauma and surgery, including tooth extraction, may be the first evidence of abnormal hemostasis in those with mild disease. In females, menorrhagia and profuse postpartum bleeding may occur. Bleeding associated with von Willebrand's disease may be severe and lead to anemia and shock, but unlike what is seen in clients with hemophilia, deep bleeding into joints and muscles is rare. Options 1, 2, and 3 are characteristic of those signs found in clients with hemophilia.
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Which assessment finding should the nurse expect to note in the child hospitalized with a diagnosis of nephrotic syndrome?
- A. Weight loss
- B. Constipation
- C. Hypotension
- D. Abdominal pain
Correct Answer: D
Rationale: Clinical manifestations associated with nephrotic syndrome include edema, anorexia, fatigue, and abdominal pain from the presence of extra fluid in the peritoneal cavity. Diarrhea caused by the edema of the bowel occurs and may cause decreased absorption of nutrients. Increased weight from fluid buildup and a normal blood pressure are noted.
The nurse performs an Allen's test before blood is drawn from the radial artery for an arterial blood gas (ABG) assessment. This intervention is done to determine the collateral circulatory adequacy of which arterial vessel?
- A. Ulnar
- B. Carotid
- C. Brachial
- D. Femoral
Correct Answer: A
Rationale: Before radial puncture for obtaining an arterial specimen for ABGs, Allen's test is performed to determine adequate ulnar circulation. Failure to assess collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Allen's test does not determine the adequacy of carotid, brachial, or femoral circulation.
The nurse prepares to administer a continuous intravenous (IV) infusion through a peripheral IV to a dehydrated client. Which priority assessment should the nurse obtain before initiating the IV infusion?
- A. Daily body weight
- B. Serum electrolytes
- C. Intake and output records
- D. Identifying the client's dominant side
Correct Answer: A
Rationale: The nurse obtains the client's baseline body weight as a priority before beginning the IV infusion because body weight is a sensitive and specific indicator of fluid volume status when body weights are compared on a daily basis. This means that as a client receives or accumulates fluid, body weight quickly and proportionately increases and vice versa. The remaining options may also be reasonable assessments to complete before initiating an IV infusion. However, intake, output, and serum electrolytes are potentially affected by more confounding factors; thus, they are less specific and sensitive to fluctuations in body fluid. Determining the client's dominant side assists in deciding a site for inserting the initial IV catheter, but it provides no information about fluid volume status.
Which aspect should the nurse focus on when assessing a client for the vegetative signs of depression? Select all that apply.
- A. Weight
- B. Appetite
- C. Sleep patterns
- D. Suicidal ideations
- E. Psychomotor activity
- F. Rational decision making
Correct Answer: A,B,C,E
Rationale: The vegetative signs of depression are changes in physiological functioning that occur during depression. These include changes in appetite, weight, sleep patterns, and psychomotor activity. The remaining options represent psychological assessment categories.
When assessing a child which finding would indicate the presence of Kernig's sign?
- A. Calf pain when the foot is dorsiflexed
- B. Pain when the chin is pulled down to the chest
- C. The inability of the child to extend the legs fully when lying supine
- D. The flexion of the hips when the neck is flexed from a lying position
Correct Answer: C
Rationale: Kernig's sign is the inability of the child to extend the legs fully when lying supine. Brudzinski's sign is flexion of the hips when the neck is flexed from a supine position. Both of these signs are frequently present in clients with bacterial meningitis. Nuchal rigidity is also present with bacterial meningitis, and it occurs when pain prevents the child from touching the chin to the chest. Homans' sign is elicited when pain occurs in the calf region when the foot is dorsiflexed.