Nokea
A patient is scheduled for an MRI and asks what to expect. Which of the following responses by the nurse is best?
- A. "It is the measurement of muscle contraction after stimulation by tiny needle electrodes."
- B. "Electrodes will be placed on your scalp to measure activity of the brain."
- C. "A scan of the brain will be done after injection of radioisotope."
- D. "It is a noninvasive test that uses magnetic energy to visualize internal parts."
Correct Answer: D
Rationale: The best response by the nurse in this scenario is option D: "It is a noninvasive test that uses magnetic energy to visualize internal parts." This response provides a clear and accurate description of what an MRI (Magnetic Resonance Imaging) involves. An MRI is a diagnostic test that uses a powerful magnetic field, radio waves, and a computer to create detailed images of the internal structures of the body. It is noninvasive, meaning there are no needles, electrodes, or injections involved. By explaining the procedure in a simple and understandable way, the nurse can help alleviate any anxiety or concerns the patient may have about the upcoming MRI.
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Which assessment finding would prompt the Rn to suspect compartment syndrome in a patient with a long leg cast?
- A. weak movement of the patient's toes
- B. decreased pedal pulses
- C. severe, unrelieved pain
- D. presence of foot pallor
Correct Answer: C
Rationale: Compartment syndrome is a serious condition that can occur when increased pressure within a muscle compartment impairs blood supply, leading to tissue ischemia and potential necrosis. Symptoms of compartment syndrome include severe, unrelieved pain that is disproportionate to the injury, as well as pain with passive stretch of the affected muscles. This pain is often described as deep, constant, and out of proportion to physical findings. Other signs that may indicate compartment syndrome include pallor, pulselessness, paresthesia, and paralysis, but the most specific and early sign is severe, unrelieved pain. While weak movement of the patient's toes and decreased pedal pulses can also be seen in compartment syndrome, they are not as specific or early indicators as severe, unrelieved pain.
An adult suffered 2nd and third degree burns over 20% of hid body 2 days ago. What is the best way to assess the client's fluid balance?
- A. Maintain strict records of intake and output
- B. Monitor skin turgor
- C. Weigh the client daily
- D. Check for edema
Correct Answer: A
Rationale: Maintaining strict records of intake and output is the best way to assess the client's fluid balance in this situation. Severe burns can lead to fluid loss, which can result in dehydration and other complications. By carefully monitoring the amount of fluid the client is taking in (intake) and the amount of fluid being eliminated from the body (output), healthcare providers can assess the client's fluid balance and make necessary adjustments to prevent dehydration or fluid overload. This approach provides accurate and specific information to guide fluid management and ensure optimal recovery for the client with burns. Monitoring skin turgor, daily weight, and checking for edema are also important measures, but maintaining strict records of intake and output is the most direct and effective method for assessing fluid balance in a client with burns.
An infant experienced an apparent life-threatening event (ALTE) and is being placed on home apnea monitoring. Parents have understood the instructions for use of a home apnea monitor when they state?
- A. "We can adjust the monitor to eliminate false alarms."
- B. "We should sleep in the same bed as our monitored infant."
- C. "We will check the monitor several times a day to be sure the alarm is working."
- D. "We will place the monitor in the crib with our infant."
Correct Answer: C
Rationale: The correct statement indicating understanding of the instructions for use of a home apnea monitor is "We will check the monitor several times a day to be sure the alarm is working." This is important because regular monitoring of the device's functioning ensures that it is able to detect any potential apnea episodes or abnormalities in the infant's breathing patterns. Checking the monitor several times a day helps in maintaining the safety and effectiveness of the monitor in alerting the parents to any potential issues with the infant's breathing. The other options are incorrect: A is incorrect because adjusting the monitor to eliminate false alarms can compromise its accuracy, B is incorrect as the infant should sleep in a separate safe sleep environment to reduce the risk of SIDS, and D is incorrect as the monitor should be placed near the infant's crib but not directly in it for safety reasons.
A school-age child has been admitted to the hospital with an exacerbation of nephrotic syndrome. Which clinical manifestations should the nurse expect to assess? (Select all that apply.)
- A. Weight loss
- B. Facial edema
- C. Cloudy smoky brown-colored urine
- D. Fatigue
Correct Answer: B
Rationale: Facial edema is a common clinical manifestation of nephrotic syndrome due to fluid retention and protein loss in the urine.
Building a tower by a 22-month-old child requires
- A. visual-motor coordination
- B. uses objects and actions in combination
- C. gross motor to solve problems
- D. fine motor and symbolic thought
Correct Answer: D
Rationale: At this age, building a tower involves fine motor skills and symbolic thinking.