Nokea
The nurse knows that Parkinson's disease a progressive neurologic disorder is characterized by:
- A. Bradykinesia
- B. Tremor
- C. Muscle rigidity
- D. All of the above
Correct Answer: D
Rationale: Parkinson's disease is a progressive neurologic disorder that is characterized by a triad of symptoms known as the classic Parkinsonian triad. These symptoms include bradykinesia (slowness of movement), tremor (involuntary shaking), and muscle rigidity (stiffness of the muscles). Therefore, all of the given choices are correct in describing the characteristics of Parkinson's disease.
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The nurse is caring for a 5-year-old child with impetigo contagiosa. The parents ask the nurse what will happen to their child's skin after the infection has subsided and healed. Which answer should the nurse give?
- A. There will be no scarring.
- B. There may be some pigmented spots.
- C. It is likely there will be some slightly depressed scars.
- D. There will be some atrophic white scars.
Correct Answer: A
Rationale: Impetigo contagiosa typically does not leave scarring once it has subsided and healed. This skin infection primarily affects the superficial layers of the skin and does not cause damage deep enough to result in scarring. While there may be some temporary pigmented spots or mild changes in skin color after the infection resolves, scarring is not a common outcome of impetigo contagiosa in most cases. Thus, the nurse should reassure the parents that their child's skin is not likely to have any scarring after the infection has healed.
A 36-year-old man is scheduled for a unilateral orchiectomy for treatment of testicular cancer. He is withdrawn and does not interact with the nurse. Which action is most appropriate?
- A. Identify the problem with a nursing diagnosis of impaired communication related to the diagnosis of cancer
- B. Set a patient outcome that the patient will verbalize his concerns about his diagnosis
- C. Ask the patient whether he is worried about future sexual functioning
- D. Say, "You seem quiet. Are you feeling concerned about your diagnosis or treatment?"
Correct Answer: D
Rationale: Option D is the most appropriate action in this scenario because it demonstrates empathy and opens the door for the patient to express his concerns. By acknowledging the patient's withdrawn behavior and directly inquiring about his feelings regarding the diagnosis or treatment, the nurse creates an opportunity for the patient to share his thoughts and concerns. This open-ended question allows the patient to express himself without any assumptions or judgments. It shows that the nurse is attentive, supportive, and willing to listen to the patient's emotional needs during this challenging time.
The nurse would monitor the client for which of the following?
- A. Trousseau's sign
- B. Hypoglycemia
- C. Hypokalamia
- D. Respiratory changes
Correct Answer: A
Rationale: Trousseau's sign is a clinical sign characterized by carpal spasm induced by inflating a blood pressure cuff above the systolic pressure for a few minutes. It is indicative of hypocalcemia, specifically low calcium levels in the blood. Therefore, the nurse would monitor the client for Trousseau's sign to assess for potential hypocalcemia. This could prompt the healthcare provider to order further diagnostic tests or interventions to address the underlying calcium imbalance. Options B, C, and D do not directly relate to monitoring for Trousseau's sign.
A 52-year old female tells the nurse that she has found a painless lump in her right breast during her monthly self- examination. Which assessment finding would strongly suggest that this client's lump is cancerous?
- A. Eversion of the right nipple and mobile mass
- B. Mobile mass that is soft and easily
- C. Non-mobile mass with irregular edges delineated
- D. Non palpable right axillary lymph nodes
Correct Answer: C
Rationale: The assessment finding that strongly suggests that the client's lump is cancerous is a non-mobile mass with irregular edges delineated. Generally, cancerous breast lumps tend to have irregular shapes/edges and lack mobility. This finding is concerning for malignancy because it indicates that the lump is fixed in place and possibly invading nearby tissues, which are characteristics often associated with cancerous tumors. It's essential for the client to undergo further diagnostic tests, such as a biopsy, to confirm the presence of cancer and establish a proper treatment plan.
A client asks the nurse about the four-point gait when partial weight bearing is permitted. What is the nurse's BEST response?
- A. move the right crutch ahead, then follow with the left foot
- B. move both crutches forward together, then swing legs through
- C. move the left crutch and the right foot forward together
- D. move both crutches and the weaker leg forward at the same time
Correct Answer: A
Rationale: In the four-point gait when partial weight bearing is permitted, the correct technique is to move the right crutch ahead, then follow with the left foot. This technique provides the most stability and support for the individual while allowing for proper weight distribution and balance. Moving the crutches and legs in a coordinated fashion helps prevent falls and ensures the safe ambulation of the client.