Nokea
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.
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A tuberculosis intradermal skin test to detect tuberculosis infection is given to a high-risk adolescent. How long after the test is administered should the result be evaluated?
- A. Immediately
- B. Within 24 hours
- C. In 48 to 72 hours
- D. After 5 days
Correct Answer: C
Rationale: The tuberculin skin test reaction peaks in 48 to 72 hours, making this the optimal time for evaluation.
Following are correctly matched
- A. Tuberous sclerosis-Cardiac rhabdomyoma
- B. WPW syndrome-SVT
- C. Maternal SLE-Irreversible complete heart block
- D. Parvo B19-Roseola infectiosum
Correct Answer: A
Rationale: Tuberous sclerosis is associated with cardiac rhabdomyomas.
Which among the following is a systolic event?
- A. E wave
- B. L wave
- C. A wave
- D. S' wave
Correct Answer: D
Rationale: S' wave is a systolic event observed in echocardiography.
Patrick, a healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client’s fluid intake because fluid overload may cause:
- A. Cerebral edema
- B. Dehydration
- C. Heart failure
- D. Hypovolemic shock
Correct Answer: A
Rationale: Fluid overload in a patient with meningitis can exacerbate cerebral edema, increasing intracranial pressure and worsening the condition.
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.