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A one month old infant is admitted for confirmation of the diagnosis of ventricular septal defect. During the initial admission assessment, the nurse would expect to find:
- A. Bradycardia at rest
- B. Bounding peripheral pulses
- C. An activity related cyanosis
- D. A murmur at the left sternal border. 105
Correct Answer: D
Rationale: A ventricular septal defect (VSD) is a congenital heart defect where there is an abnormal opening between the two ventricles of the heart. One of the hallmark signs of VSD is the presence of a murmur, specifically a holosystolic murmur, which is typically heard best at the left sternal border due to the turbulent blood flow through the defect. This murmur is a key finding during the initial assessment of a patient with a suspected VSD. Other common symptoms of VSD include poor feeding, failure to thrive, tachypnea, and frequent respiratory infections.
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Which assessment action will help the nurse determine if the patient with Bell's Palsy is receiving adequate nutrition?
- A. Monitor meal trays
- B. Check twice-weekly weights
- C. Measure intake and output
- D. Assess swallowing reflex
Correct Answer: D
Rationale: By assessing the patient's swallowing reflex, the nurse can determine if the patient is able to swallow food and liquids properly, which is crucial for adequate nutrition intake. Bell's Palsy can affect facial muscles, including those involved in chewing and swallowing. A impaired swallowing reflex can lead to difficulties in eating and drinking, which in turn may affect the patient's nutrition status. Monitoring meal trays (A) may not provide direct information about the patient's ability to swallow, as a patient may not be able to communicate swallowing difficulties. Checking twice-weekly weights (B) may indicate weight changes, but it may not necessarily give insight into nutrition adequacy related to swallowing ability. Measuring intake and output (C) may help track calorie intake and fluid balance, but it may not specifically address swallowing issues that can impact nutrition in a patient with Bell's Palsy. Assessing the swallowing reflex (D) directly addresses the patient's ability to consume food and
Many factors in nasopharyngeal carcinoma patients may affect the prognosis. Which of the following carries the worst outcome?
- A. elevated lactate dehydrogenase (LDH) level
- B. advanced disease
- C. extensive cervical lymph node involvement
- D. evidence of Epstein-Barr virus (EBV) DNA
Correct Answer: A
Rationale: Elevated LDH levels are strongly associated with aggressive disease and poor prognosis.
The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for?
- A. Actinic
- B. Arcus
- C. Asymmetry
- D. Assessment
Correct Answer: C
Rationale: In the ABCD method used to assess skin lesions for possible skin cancer, the letter A stands for Asymmetry. Asymmetry refers to the irregular shape of the lesion when one half of the lesion does not match the other half. Lesions that are symmetrical are less likely to be concerning for skin cancer, while asymmetrical lesions should be further evaluated by a healthcare professional. This characteristic helps in identifying potentially worrisome skin lesions early on for appropriate management.
The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?
- A. Refer for immediate medical evaluation.
- B. Continue assessment to determine cause of neck pain.
- C. Ask parent when neck was injured.
- D. Record "head lag" on assessment record, and continue assessment of child.
Correct Answer: A
Rationale: Referring the child for immediate medical evaluation is the most appropriate action in this scenario. The symptoms described, including hyperextension of the head (opisthotonos) with pain on flexion, are concerning for meningitis, a serious infection that can rapidly progress and lead to serious complications if not treated promptly. Seeking immediate medical intervention is crucial to assess and manage the child's condition effectively. Continuing with the assessment or asking about a neck injury is not recommended as the priority is to address the potential medical emergency. Recording the "head lag" without taking immediate action could delay necessary medical treatment.
By the age of 7 months, the infant is able to do all the following EXCEPT
- A. transfer object from hand to hand
- B. actively bounces
- C. uses radial palm grasp
- D. cruises
Correct Answer: D
Rationale: Cruising typically occurs later, around 9-10 months.