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A nurse caring for a patient with a herniated lumbar disk develops a plan of care for impaired mobility related to nerve compression. Which patient outcome indicates that the plan has been successful?
- A. The patient rates the pain at 3 to 4 on a 0 to 10 scale
- B. The patient has full ROM of the upper extremities
- C. The patient demonstrates correct self-administration of analgesics
- D. The patient is able to ambulate 25 feet without pain
Correct Answer: D
Rationale: The patient being able to ambulate 25 feet without pain is the most appropriate outcome to indicate the success of the plan for impaired mobility related to nerve compression due to a herniated lumbar disk. This outcome directly reflects an improvement in mobility, which is the primary goal when addressing impaired mobility caused by nerve compression. A reduction in pain intensity (choice A) is important but not as specific to mobility impairment. Having full range of motion (choice B) in the upper extremities is not directly related to the issue of lumbar disk herniation. Correct self-administration of analgesics (choice C) is important for pain management but does not directly reflect improvement in mobility.
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Which is the most critical physiologic change required of the newborn?
- A. Closure of fetal shunts in the heart
- B. Stabilization of fluid and electrolytes
- C. Body-temperature maintenance
- D. Onset of breathing
Correct Answer: D
Rationale: The most critical physiologic change required of the newborn is the onset of breathing. Prior to birth, the fetus receives oxygen from the mother's blood through the placenta. However, once the newborn is delivered, it needs to begin breathing on its own to support oxygen exchange and remove carbon dioxide from the body. The respiratory system must transition from a fluid-filled state in the womb to an air-filled state outside the womb. The onset of breathing is essential for the newborn's survival and initiates the process of oxygenation of tissues and removal of carbon dioxide, which are vital for metabolism and overall physiological functioning. While closure of fetal shunts, stabilization of fluid and electrolytes, and body-temperature maintenance are also important changes that occur in the newborn, the onset of breathing is the most critical to ensure proper oxygenation of the body's tissues.
The major manifestation of nephrotic syndrome is:
- A. hematuria.
- B. hyperalbuminemia.
- C. edema.
- D. anemia.
Correct Answer: C
Rationale: The major manifestation of nephrotic syndrome is edema. Nephrotic syndrome is a kidney disorder characterized by increased permeability of the glomerular filtration barrier, leading to excessive protein loss in the urine. This results in low levels of protein in the blood, particularly albumin, leading to a decrease in oncotic pressure. The decreased oncotic pressure causes fluid to accumulate in the interstitial spaces, leading to edema formation. Patients with nephrotic syndrome typically present with periorbital edema, pedal edema, and ascites due to the fluid redistribution in the body. Hematuria, hyperalbuminemia, and anemia are not typically the primary manifestations of nephrotic syndrome.
A nurse is assessing a 12-month-old infant. Which statement best describes the infant's physical development a nurse should expect to find?
- A. Anterior fontanel closes by age 6 to 10 months.
- B. Binocularity is well established by age 8 months.
- C. Birth weight doubles by age 5 months and triples by age 1 year.
- D. Maternal iron stores persist during the first 12 months of life.
Correct Answer: C
Rationale: The statement that best describes the infant's physical development that a nurse should expect to find is that birth weight doubles by age 5 months and triples by age 1 year. This characteristic growth pattern is typical in the first year of life. Infants usually regain their birth weight by around 2 weeks of age, double it by about 5 months, and triple it by 1 year. This steady growth reflects the healthy development of the infant and is an important marker of overall well-being and nutrition. It is a key aspect that healthcare providers, including nurses, monitor closely to ensure the infant is thriving.
The nurse is teaching nursing students about shock that occurs in children. What is one of the most frequent causes of hypovolemic shock in children?
- A. Sepsis
- B. Blood loss
- C. Anaphylaxis
- D. Congenital heart disease
Correct Answer: B
Rationale: One of the most frequent causes of hypovolemic shock in children is blood loss. Children are at risk for blood loss due to trauma, surgical procedures, gastrointestinal bleeding, or other conditions that result in significant blood volume reduction. Blood loss leads to a decrease in circulating blood volume, which in turn reduces tissue perfusion and oxygen delivery to vital organs. This results in hypovolemic shock, where the heart is unable to pump sufficient blood to meet the body's needs, leading to organ dysfunction and potentially life-threatening complications. Therefore, recognizing and addressing blood loss promptly is essential in managing hypovolemic shock in children.
Gender identity disorder (GID) is characterized by intense and persistent cross-gender identification and discomfort with one’s own sex. In early school-age children, the manifestation that is LEAST likely considered as GID is
- A. dressing as a member of the opposite sex (i.e., cross dressing)
- B. strong belief that one is the opposite sex
- C. exclusive preference for cross sex roles
- D. playing with toys designed for the opposite sex
Correct Answer: D
Rationale: Playing with toys designed for the opposite sex does not necessarily indicate GID, as it is a common exploratory behavior in childhood.