Nokea
A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse?
- A. Serum sodium of 185 mEq/L
- B. Urine output of 3000 mL per hour.
- C. Blood pressure of 90/60 mmHg.
- D. Potassium level of 4.5 mEq/L.
Correct Answer: A
Rationale: A serum sodium level of 185 mEq/L indicates severe hypernatremia, which is life-threatening and requires immediate intervention.
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All of the following are minor criteria in the latest Revised Jones criteria for rheumatic fever in moderate-high risk population except
- A. Monoarthalgia
- B. Fever with body temperature ≥ 38.5°C
- C. ESR 230 mm/hour
- D. Prolonged PR interval
Correct Answer: C
Rationale: ESR 230 mm/hour is not a minor criterion in the Revised Jones criteria for rheumatic fever.
In normal neonates:
- A. Extracellular fluid volume exceeds intracellular fluid volume
- B. In a term baby, plasma calcium levels exceed that of the mother
- C. Clamping the umbilical cord after cessation of cord pulsations increases the blood volume by 20% in the baby
- D. There are two arteries and one vein in the umbilical cord
Correct Answer: A
Rationale: In neonates, extracellular fluid volume is greater than intracellular fluid volume, reflecting the transition from intrauterine to extrauterine life.
Increased fetal haemoglobin is seen in:
- A. Haemoglobin H disease
- B. β-thalassaemia major
- C. Fanconi's anaemia
- D. Pyruvate kinase deficiency
Correct Answer: B
Rationale: Increased fetal haemoglobin (HbF) is a compensatory mechanism in β-thalassaemia major to counteract the reduced production of adult haemoglobin (HbA).
A nurse assists a male client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to 'freeze' and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond?
- A. Re-orient the client to his present location and circumstances
- B. Confirm that this is an effective technique to help with ambulation
- C. Assist the client to a carpeted area where he can walk more easily
- D. Plan to assess the client's cognition after returning to his room
Correct Answer: B
Rationale: Pretending to step over a crack is a known technique that can help clients with PD overcome freezing episodes.
Concerning insulin-dependent diabetes mellitus in children:
- A. Microangiopathic changes are rare before puberty
- B. Isophane is shorter acting than soluble insulin
- C. Lipohypertrophy is more common than lipo-atrophy
- D. Fructosamine can be used to monitor glucose control
Correct Answer: A
Rationale: Microangiopathic changes are indeed rare before puberty in children with insulin-dependent diabetes mellitus. Isophane is not shorter acting than soluble insulin, and fructosamine is used to monitor glucose control.