Nokea
A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action?
- A. Administer the first dose of antibiotic therapy
- B. Observe the color, consistency, and amount of sputum
- C. Encourage the client to consume plenty of warm liquids
- D. Send the specimen to the lab for analysis
Correct Answer: B
Rationale: Observing the color, consistency, and amount of sputum helps in assessing the nature of the infection and guides further treatment. Sending the specimen to the lab is important but not the first action.
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The main risk factor for developing deep vein thrombosis is:
- A. Prolonged immobility
- B. Age
- C. Obesity
- D. Family history
Correct Answer: A
Rationale: Prolonged immobility, such as during long flights or post-surgery, is a significant risk factor for developing deep vein thrombosis (DVT).
Which of the following is a neurocutaneous syndrome without cutaneous manifestations?
- A. Sturge-Weber syndrome
- B. Tuberous sclerosis
- C. Ataxia telangiectasia
- D. Von Hippel-Lindau disease
Correct Answer: D
Rationale: Von Hippel-Lindau disease is a neurocutaneous syndrome that primarily affects internal organs and often lacks cutaneous manifestations.
The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, “Why do my child’s fingertips look like that?†On what understanding does the nurse base a response?
- A. Clubbing occurs as a result of untreated congestive heart failure.
- B. Clubbing occurs as a result of a left-to-right shunting of blood.
- C. Clubbing occurs as a result of decreased cardiac output.
- D. Clubbing occurs as a result of chronic hypoxia.
Correct Answer: D
Rationale: Clubbing of the fingers develops in response to chronic hypoxia.
Features that would increase suspicion of cerebral palsy at age 9 months include:
- A. Presence of Moro reflex
- B. Abductor spasm
- C. Hand dominance
- D. Grasp reflex
Correct Answer: C
Rationale: Hand dominance at 9 months is a red flag for cerebral palsy. The persistence of primitive reflexes like the Moro and grasp reflexes can also be indicative.
What is the most likely congenital heart lesion in a newborn with Trisomy 21?
- A. AVSD
- B. Tetralogy of Fallot
- C. Ventricular septal defect
- D. Pulmonary stenosis
Correct Answer: A
Rationale: Atrioventricular septal defect (AVSD) is highly associated with Trisomy 21 and is the most likely congenital heart lesion in these infants.