Nokea
A patient is being treated in the Neurology Unit for Meningitis. Which of these is a priority assessment for the nurse to make?
- A. Assess the patient for nuchal rigidity
- B. Determine the patient's past exposure to infectious organisms
- C. Check the patient's WBC lab values
- D. Monitor for increased lethargy and drowsiness
Correct Answer: D
Rationale: Monitoring for increased lethargy and drowsiness is crucial as these symptoms indicate a decreased level of consciousness, which is the cardinal sign of increased Intracranial Pressure (ICP). Elevated ICP can lead to serious complications and requires immediate intervention. Assessing for nuchal rigidity is important in suspected cases of meningitis but monitoring lethargy and drowsiness takes precedence due to its direct correlation with ICP. Determining past exposure to infectious organisms and checking WBC lab values are important for diagnosing and treating meningitis but do not directly address the immediate concern of increased ICP.
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Which clinical manifestations are recognized in nephrotic syndrome?
- A. Hematuria, bacteriuria, weight gain
- B. Gross hematuria, albuminuria, fever
- C. Hypertension, weight loss, proteinuria
- D. Massive proteinuria, hypoalbuminemia, edema
Correct Answer: D
Rationale: Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, and edema. In this syndrome, there is loss of proteins, particularly albumin, in the urine leading to hypoalbuminemia, fluid retention, and subsequent edema. This results in elevated lipid levels like hypercholesterolemia, but not hypertension. Therefore, choices A, B, and C are incorrect. Hematuria, bacteriuria, fever, and weight loss are not typically associated with nephrotic syndrome, distinguishing it from other kidney disorders.
Which of the following signs is NOT indicative of increased intracranial pressure?
- A. Decreased level of consciousness
- B. Projectile vomiting
- C. Sluggish pupil dilation
- D. Increased heart rate
Correct Answer: D
Rationale: Increased intracranial pressure can lead to serious complications if not promptly addressed. Common signs of increased intracranial pressure include decreased level of consciousness, sluggish pupil dilation, abnormal respirations, and projectile vomiting. However, an increased heart rate is not a typical sign associated with increased intracranial pressure. It is important for healthcare providers to recognize these signs early to prevent severe consequences such as brain herniation.
The nurse reviews the record of a child who is suspected to have glomerulonephritis and expects to note which finding that is associated with this diagnosis?
- A. Hypotension
- B. Brown-colored urine
- C. Low urinary specific gravity
- D. Low blood urea nitrogen level
Correct Answer: B
Rationale: Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria resulting in dark, smoky, cola-colored, or brown-colored urine is a classic symptom of glomerulonephritis. Hypertension is also common. Blood urea nitrogen levels may be elevated. A moderately elevated to high urinary specific gravity is associated with glomerulonephritis.
The healthcare provider assesses a patient suspected of having an asthma attack. Which of the following is a common clinical manifestation of this condition?
- A. Audible crackles and orthopnea
- B. An audible wheeze and use of accessory muscles
- C. Audible crackles and use of accessory muscles
- D. Audible wheeze and orthopnea
Correct Answer: B
Rationale: Choice B, 'An audible wheeze and use of accessory muscles,' is the correct answer. In asthma, patients commonly present with wheezing due to airway constriction and the use of accessory muscles to aid in breathing. Audible crackles (rales) are more commonly associated with conditions like pneumonia, congestive heart failure, or pulmonary fibrosis. Orthopnea, which is difficulty breathing while lying flat, is typically seen in conditions like heart failure or chronic obstructive pulmonary disease, rather than asthma. Choice C is incorrect as crackles are not a typical finding in asthma. Choice D is incorrect as orthopnea is not a common clinical manifestation of asthma.
Which question should the nurse ask the parents of a child suspected of having glomerulonephritis?
- A. Did your child fall off a bike onto the handlebars?
- B. Has the child had persistent nausea and vomiting?
- C. Has the child been itching or had a rash anytime in the last week?
- D. Has the child had a sore throat or a throat infection in the last few weeks?
Correct Answer: D
Rationale: Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Group A β-hemolytic streptococcal infection is a common cause of glomerulonephritis. Children with glomerulonephritis often develop symptoms after a throat infection caused by streptococcal bacteria. Therefore, asking about a sore throat or throat infection in the last few weeks is crucial to assess the possible link to glomerulonephritis. Choices A, B, and C are not directly associated with the pathophysiology of glomerulonephritis. Asking about falling off a bike, nausea and vomiting, or itching and rash do not provide relevant information for assessing glomerulonephritis in this context.