Nokea
A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?
- A. Facial puffiness and periorbital edema
- B. Hematocrit of 30%
- C. Cold and dry skin
- D. Further decline in level of consciousness
Correct Answer: D
Rationale: A further decline in level of consciousness could indicate myxedema coma, a life-threatening complication of hypothyroidism.
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A female client who was involved in a motor vehicle collision with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? Select all that apply.
- A. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure. Verify pedal pulses using a doppler pulse device. Evaluate the application of the splint to the left leg
- B. Verify pedal pulses using a Doppler pulse device
- C. Evaluate the application of the splint to the left leg.
- D. Administer pain medication to alleviate discomfort.
Correct Answer: A
Rationale: Monitoring for signs of compartment syndrome and verifying pulses are critical to ensure adequate circulation and prevent complications.
In febrile convulsions:
- A. Familial predisposition is the same as in idiopathic epilepsy
- B. Carbamazepine achieves good seizure control
- C. Shigella dysentery may be a cause
- D. Deafness can occur if seizure is prolonged
Correct Answer: C
Rationale: Shigella dysentery, a bacterial infection, can cause febrile convulsions in children due to the high fever associated with the infection.
Guillain-Barre syndrome (GBS) is excluded by:
- A. A normal CSF
- B. The presence of autonomic neuropathy
- C. Distinct sensory level
- D. Ophthalmoplegia
Correct Answer: C
Rationale: A distinct sensory level is not a feature of GBS, which typically presents with ascending symmetrical weakness and absent reflexes.
Which of the following conditions results primarily from mutation in the gene encoding Vitamin D receptor?
- A. Vitamin D dependent rickets type 1
- B. Vitamin D dependent rickets type 2
- C. X-linked hypophosphatemic rickets
- D. Autosomal dominant hypophosphatemic rickets
Correct Answer: B
Rationale: Vitamin D dependent rickets type 2 is caused by mutations in the vitamin D receptor gene, leading to resistance to vitamin D.
A father asks why his child with tetralogy of Fallot seems to favor a squatting position. What is the nurse’s best response?
- A. Squatting increases the return of venous blood back to the heart.
- B. Squatting decreases arterial blood flow away from the heart.
- C. Squatting is a common resting position when a child is tachycardic.
- D. Squatting increases the workload of the heart.
Correct Answer: A
Rationale: The squatting position allows the child to breathe more easily because systemic venous return is increased.