Nokea
A male client complains of pain in his right calf, and the nurse determines that his calf is edematous and deep red. What intervention has the highest priority?
- A. Tell the client to remain in bed
- B. Apply warm compresses to the affected leg.
- C. Administer pain medication as prescribed.
- D. Encourage the client to elevate the affected leg.
Correct Answer: A
Rationale: The symptoms suggest deep vein thrombosis (DVT). Bed rest prevents dislodgment of the clot, reducing the risk of pulmonary embolism.
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A child with rheumatic fever begins involuntary, purposeless movements of her limbs. What does the nurse recognize that this indicates?
- A. Seizure activity
- B. Hypoxia
- C. Sydenham’s chorea
- D. Decreasing level of consciousness
Correct Answer: C
Rationale: As the effects of rheumatic fever affect the central nervous system, the child may develop Sydenham’s chorea, manifested by involuntary, purposeless movements of the limbs.
One of the following is a sign of right-sided heart failure of the patient
- A. tachypnea
- B. orthopnea
- C. wheezing
- D. pulmonary edema
Correct Answer: B
Rationale: Right-sided heart failure typically presents with systemic signs like orthopnea and peripheral edema rather than pulmonary edema.
List FOUR differential diagnoses aside from aortic coarctation for a two-week old infant presenting with tachypnea and poor femoral pulses.
- A. Tachycardia induced cardiomyopathy
- B. Critical aortic stenosis
- C. Dilated cardiomyopathy
- D. Myocarditis
Correct Answer: A
Rationale: Differential diagnoses in such cases can include non-structural heart conditions like tachycardia induced cardiomyopathy, which affects the heart's ability to pump effectively.
Coxsackie viruses are implicated in:
- A. Herpangina
- B. Dermatitis herpetiformis
- C. Meningitis
- D. Orchitis
Correct Answer: A
Rationale: Coxsackie viruses are a common cause of herpangina. They can also cause meningitis and orchitis, but dermatitis herpetiformis is not associated with Coxsackie viruses.
What are THREE classes of medication used to treat giant coronary artery aneurysms in Kawasaki Disease?
- A. ACE inhibitor
- B. Beta blocker
- C. Statin
- D. All of the above
Correct Answer: D
Rationale: These medications are typically used in the management of giant coronary artery aneurysms to manage cardiovascular risks.