Nokea
A client is scheduled for an arteriogram using a radiopaque dye. What is the most important information the nurse should determine before the procedure to assure the client's safety?
- A. Vital signs
- B. Intake and output
- C. Height and weight
- D. Allergy to iodine or shellfish
Correct Answer: D
Rationale: Allergy to iodine or seafood is associated with allergy to the radiopaque dye that is used for medical imaging examinations. Informed consent is necessary because an arteriogram requires the injection of a radiopaque dye into the blood vessel. Although the remaining options are components of the preprocedure assessment, the risks of allergic reaction and possible anaphylaxis are the most critical to the client's safety.
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The nurse assessing the level of consciousness of a child with a head injury documents that the child is obtunded. On the basis of this documentation, which observation did the nurse note?
- A. The child is unable to think clearly and rapidly.
- B. The child is unable to recognize place or person.
- C. The child always requires considerable stimulation for arousal.
- D. The child has limited interaction with the environment unless aroused.
Correct Answer: D
Rationale: If the child is obtunded, the child sleeps unless aroused and, when aroused, has limited interaction with the environment. The remaining options describe confusion, disorientation, and stupor.
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.
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.
A child experienced a basilar skull fracture that resulted in the presence of Battle's sign. Which should the nurse expect to observe in the child?
- A. Bruising behind the ear
- B. The presence of epistaxis
- C. A bruised periorbital area
- D. An edematous periorbital area
Correct Answer: A
Rationale: The most serious type of skull fracture is a basilar skull fracture. Two classic findings associated with this type of skull fracture are Battle's sign and raccoon eyes. Battle's sign is the presence of bruising or ecchymosis behind the ear caused by a leaking of blood into the mastoid sinuses. Raccoon eyes occur as a result of blood leaking into the frontal sinus and causing an edematous and bruised periorbital area.
The nurse caring for a child diagnosed with rubeola (measles) notes that the primary health care provider has documented the presence of Koplik's spots. On the basis of this documentation, which observation is expected?
- A. Pinpoint petechiae noted on both legs
- B. Whitish vesicles located across the chest
- C. Petechiae spots that are reddish and pinpoint on the soft palate
- D. Small, blue-white spots with a red base found on the buccal mucosa
Correct Answer: D
Rationale: In rubeola (measles), Koplik's spots appear approximately 2 days before the appearance of the rash. These are small, blue-white spots with a red base that are found on the buccal mucosa. The spots last approximately 3 days, after which time they slough off. Based on this information, the remaining options are all incorrect.