Nokea
A college student is asking the nurse about his grandfather, who just received a diagnosis of Huntington's disease. The student wants to know if he will have the disease, too. What should the nurse tell the student? Select all that apply.
- A. Huntington's disease affects men more than women.'
- B. Huntington's disease is an autosomal dominant disease.'
- C. Huntington's disease does not skip a generation.'
- D. Huntington's disease is a treatable disease.'
- E. There is a 75% chance you will have the disease.'
Correct Answer: B,C
Rationale: Huntington's disease is an autosomal dominant disorder, meaning a 50% chance of inheritance if one parent is affected, and it typically does not skip generations. It affects men and women equally, is not treatable (only symptom management is available), and the risk is not 75% but 50%.
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Which question is asked more than any other root cause analysis activity?
- A. What?
- B. Why?
- C. Who?
- D. When?
Correct Answer: B
Rationale: The 'Why?' question is central to root cause analysis, as it drives the investigation into the underlying causes of an event through techniques like the '5 Whys.'
A client with a history of chronic heart failure is prescribed digoxin (Lanoxin). The nurse should monitor the client for which of the following signs of toxicity? Select all that apply.
- A. Nausea.
- B. Visual disturbances.
- C. Tachycardia.
- D. Fatigue.
- E. Hypokalemia.
Correct Answer: A, B, D
Rationale: Digoxin toxicity presents with nausea, visual disturbances (e.g., yellow vision), and fatigue. Hypokalemia increases toxicity risk but is not a symptom.
The nurse is caring for a client with a tracheostomy. Which of the following actions is the highest priority to maintain airway patency?
- A. Suctioning the tracheostomy as needed.
- B. Cleaning the tracheostomy site daily.
- C. Humidifying the inspired air.
- D. Securing the tracheostomy tube.
Correct Answer: A
Rationale: Suctioning as needed is the highest priority to maintain airway patency by removing mucus or obstructions from the tracheostomy.
The nurse is caring for a client who is having an acute asthma attack. The nurse should notify the physician of which of the following?
- A. Loud wheezing.
- B. Tenacious, thick sputum.
- C. Decreased breath sounds.
- D. Persistent cough.
Correct Answer: C
Rationale: Decreased breath sounds indicate severe airway obstruction in an asthma attack, requiring immediate physician notification.
A 9-year-old child is newly diagnosed with type 1 diabetes mellitus. The nurse is planning for home care with the child and the family and determines that which is an age-appropriate activity for health maintenance?
- A. Administering insulin drawn up by an adult
- B. Self-administering insulin with adult supervision
- C. Making independent decisions with regard to sliding-scale coverage of insulin
- D. Having an adult assist in the self-administration of insulin and glucose monitoring
Correct Answer: B
Rationale: School-age children have the cognitive and motor skills to draw up and administer insulin with adult supervision. Developmentally, they do not yet have the maturity to make independent decisions such as about sliding-scale coverage without adult validation. Options requiring adult to manage insulin administration and glucose monitoring suppress the maximum level of independence appropriate to the level of this child.