Nokea
A client asks the nurse about the four-point gait when partial weight bearing is permitted. What is the nurse's BEST response?
- A. move the right crutch ahead, then follow with the left foot
- B. move both crutches forward together, then swing legs through
- C. move the left crutch and the right foot forward together
- D. move both crutches and the weaker leg forward at the same time
Correct Answer: A
Rationale: In the four-point gait when partial weight bearing is permitted, the correct technique is to move the right crutch ahead, then follow with the left foot. This technique provides the most stability and support for the individual while allowing for proper weight distribution and balance. Moving the crutches and legs in a coordinated fashion helps prevent falls and ensures the safe ambulation of the client.
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Hemangiomas are the most common benign tumors of infancy, occurring more in full-term infants. Of the following, the most common risk factor of development of hemangioma is
- A. male infant
- B. female infant
- C. infant of diabetic mother
- D. infant delivered by cesarean section
Correct Answer: B
Rationale: Female infants are at higher risk for developing hemangiomas.
A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
- A. Weight gain
- B. Respiratory acidosis
- C. Fine motor tremors
- D. Bilateral hearing loss
Correct Answer: D
Rationale: Prolonged aspirin therapy can lead to a rare side effect known as aspirin-induced hearing loss, which manifests as bilateral hearing loss. This adverse reaction is typically associated with higher doses of aspirin and longer durations of use. It is important for healthcare providers to monitor for signs of hearing loss in patients receiving long-term aspirin therapy, especially those with rheumatoid arthritis or other inflammatory conditions, to prevent irreversible damage to the hearing. Weight gain, respiratory acidosis, and fine motor tremors are not commonly associated with prolonged aspirin therapy.
Which is the most reliable method for monitoring fluid balance?
- A. Daily intake and output
- B. Vital signs
- C. Daily weight
- D. Skin turgor
Correct Answer: A
Rationale: Monitoring daily intake and output is the most reliable method for assessing fluid balance in a patient. By accurately measuring the amount of fluids taken in through foods, drinks, and IV fluids, as well as the amount of fluids eliminated through urine, stool, vomit, and other means, healthcare providers can closely track the body's fluid balance. Discrepancies between intake and output can indicate potential issues such as dehydration or fluid overload. This method provides quantitative data that can guide appropriate interventions and treatment adjustments to maintain the patient's fluid balance within normal limits. While vital signs, daily weight, and skin turgor are also important indicators of fluid status, they may not always provide as specific or accurate information as the direct measurement of intake and output.
Nurse Amy teaches a group of nursing students about the factors that cuses biliary cirrhosis. Which factor is associated with the condition?
- A. acute viral hepatitis
- B. alcohol hepatotoxicity
- C. chronic biliary inflammation or obstruction
- D. hepatic failure with prolonged venous hepatic congestion
Correct Answer: C
Rationale: Primary biliary cirrhosis, now known as primary biliary cholangitis, is a chronic autoimmune liver disease that affects the bile ducts within the liver. The main characteristic of this condition is progressive destruction of the small bile ducts, leading to chronic biliary inflammation or obstruction. This results in the buildup of bile in the liver, causing damage and scarring (cirrhosis) over time. Factors such as acute viral hepatitis (choice A), alcohol hepatotoxicity (choice B), and hepatic failure with prolonged venous hepatic congestion (choice D) are associated with other liver conditions, but they are not specifically linked to primary biliary cholangitis.
Which describes marasmus?
- A. Deficiency of protein with an adequate supply of calories
- B. Not confined to geographic areas where food supplies are inadequate
- C. Syndrome that results solely from vitamin deficiencies
- D. Characterized by thin, wasted extremities and a prominent abdomen resulting from edema (ascites)
Correct Answer: D
Rationale: Marasmus is a form of severe malnutrition characterized by a deficiency of both calories and protein in the diet. It typically occurs in young children and is often associated with a lack of adequate food intake. The classic presentation of marasmus includes extreme wasting of muscle and fat tissues, resulting in a gaunt appearance with thin limbs and a distended abdomen due to diminished muscle and subcutaneous fat. This differentiates it from kwashiorkor, another form of severe acute malnutrition characterized by edema and a protruding belly but with retained muscle mass. Therefore, option D, characterized by thin, wasted extremities and a prominent abdomen resulting from edema (ascites), accurately describes marasmus.