Nokea
A client has a serum calcium level of 7.2mg/dl. During the physical examination, the nurse expects to assess:
- A. Trousseau's sign
- B. Hegar's sign
- C. Homan's sign
- D. Goodell's sign
Correct Answer: A
Rationale: A client with a low serum calcium level (hypocalcemia) is at risk for exhibiting Trousseau's sign. Trousseau's sign is a clinical manifestation of hypocalcemia characterized by carpal spasm induced by inflating a blood pressure cuff on the arm above the systolic pressure for a few minutes. This spasm occurs due to the increased neuromuscular irritability caused by low calcium levels. Therefore, a nurse assessing a client with a serum calcium level of 7.2mg/dl should expect to assess Trousseau's sign.
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A medical student observes that infants cry in response to another infant's cry. The MOST appropriate answer is that it represents
- A. an early sign of empathy development
- B. a sign of good hearing
- C. a startle reflex
- D. an early sign of fear development
Correct Answer: A
Rationale: Infants crying in response to others may indicate early empathy development.
At the present time, the best treatment for cancer is complete __________ before metastasis occurs:
- A. Chemotherapy
- B. Radiation
- C. Surgical removal
- D. All of the above
Correct Answer: C
Rationale: The best treatment for cancer at the present time is complete surgical removal before metastasis occurs. Surgery is often the most effective method to remove the primary tumor and eliminate cancer cells in the affected area. While chemotherapy and radiation therapy are important in treating cancer, surgical removal of the tumor provides the best chance for complete eradication of cancer cells, especially if it is done before the cancer has spread to other parts of the body.
Justine is admitted to the pediatric unit due to the occurrence of diabetic ketoacidosis signaling a new diagnosis of diabetes. The diabetes team explores the cause of the episode and take steps to prevent a recurrence. Diabetic ketoacidosis (DKA) results from an excessive accumulation of which of the following?
- A. Sodium bicarbonate from renal compensation
- B. Potassium from cell death
- C. Glucose from carbohydrate metabolism
- D. Ketone bodies from fat metabolism
Correct Answer: D
Rationale: Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when there is not enough insulin in the body. In the absence of sufficient insulin, the body is unable to use glucose for energy, leading to the breakdown of fats for fuel. This results in the excessive production of ketone bodies, specifically acetoacetate and beta-hydroxybutyrate. As the ketone bodies accumulate in the blood, they lower the blood pH, leading to acidosis. This is what causes the characteristic symptoms of DKA, such as fruity breath, deep rapid breathing, and abdominal pain. Therefore, the excessive accumulation of ketone bodies from fat metabolism is the primary cause of diabetic ketoacidosis.
The clue to need a help for a child who does not respond correctly to 'Give me' or 'Sit down' or 'Come here' when spoken without gestural cues is by age of
- A. 15 months
- B. 18 months
- C. 21 months
- D. 24 months
Correct Answer: D
Rationale: By 24 months, a child should be able to follow simple commands without gestures.
The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will be able to heat the baby's formula faster. What should the nurse recommend?
- A. Never heat a bottle in a microwave oven.
- B. Heat only 10 ounces or more.
- C. Always leave bottle top uncovered to allow heat to escape.
- D. Shake bottle vigorously for at least 30 seconds after heating.
Correct Answer: A
Rationale: The nurse should recommend never heating a bottle in a microwave oven. Microwaves do not heat liquids evenly, and there is a risk of creating hot spots in the formula, which can burn the baby's mouth and throat. It is safer to heat the formula by placing the bottle in warm water or using a bottle warmer to ensure uniform heating throughout.