Nokea
A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Select one that doesn't apply.
- A. Regular developmental screening is important to avoid secondary developmental delays.
- B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties.
- C. Developmental milestones may be slightly delayed but usually will require no additional intervention.
- D. Parent support groups are helpful for sharing strategies and managing health care issues.
Correct Answer: C
Rationale: The correct answer is 'Developmental milestones may be slightly delayed but usually will require no additional intervention.' This statement is incorrect as delayed developmental milestones in a child with cerebral palsy require interventions and constant follow-ups. Developmental monitoring is essential to track a child's growth and development over time. If any concerns are raised during monitoring, a developmental screening test should be conducted promptly to address any developmental delays or issues. Regular interventions, therapies, and support are crucial to optimize the child's development and well-being. Therefore, it is important for parents to be aware that additional interventions may be necessary to support their child's development.
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A nursing student is teaching a patient and family about epilepsy prior to the patient's discharge. For which statement should you intervene?
- A. "You should avoid consumption of all forms of alcohol."?
- B. "Wear your medical alert bracelet at all times."?
- C. "Protect your loved one's airway during a seizure."?
- D. "It's important to consult with your physician before taking over-the-counter medications."?
Correct Answer: D
Rationale: The correct answer is, "It's important to consult with your physician before taking over-the-counter medications."? Patients with epilepsy should not take over-the-counter medications without medical advice due to potential interactions with antiepileptic drugs or triggering seizures. Choices A, B, and C are all appropriate statements for a patient with epilepsy, focusing on alcohol avoidance, wearing a medical alert bracelet, and airway protection during a seizure, respectively. Choice D is incorrect because patients with epilepsy need to be cautious about medications due to possible interactions or adverse effects, so consulting with a physician is crucial before taking over-the-counter medications.
A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?
- A. Family history of heart disease
- B. Overweight
- C. Smoking
- D. Age
Correct Answer: A
Rationale: A family history of heart disease is an inherited risk factor for developing atherosclerosis. This factor is not modifiable through lifestyle changes. Studies have shown that having a first-degree relative with heart disease significantly increases the individual's risk of developing atherosclerosis. Overweight, smoking, and age are not hereditary risk factors for atherosclerosis. Overweight and smoking are lifestyle-related risk factors, while age is a non-modifiable risk factor that increases with time but is not directly inherited.
Which of the following components is associated with hypertonic dehydration?
- A. Plasma sodium levels above 150 mEq/L
- B. Fluid moves from extracellular space to intracellular space
- C. Water loss is greater than electrolyte loss
- D. Physical signs and symptoms are grossly apparent
Correct Answer: C
Rationale: The correct answer is 'Water loss is greater than electrolyte loss.' In hypertonic dehydration, there is a higher loss of water compared to electrolytes, leading to elevated concentrations of electrolytes in the body. This condition is characterized by plasma sodium levels above 150 mEq/L. As water moves from the extracellular space to the intracellular space, it results in cellular dehydration. Choice A is incorrect because the plasma sodium levels associated with hypertonic dehydration are typically above 150 mEq/L, not between 130 and 150 mEq/L. Choice B is incorrect as fluid moves from the extracellular space to the intracellular space in hypertonic dehydration. Choice D is incorrect because physical signs and symptoms may not always be grossly apparent in hypertonic dehydration.
A new mother has some questions about phenylketonuria (PKU). Which of the following
statements made by a nurse is not correct regarding PKU?
- A. A Guthrie test can check the necessary lab values.
- B. The urine has a high concentration of phenylpyruvic acid
- C. Mental deficits are often present with PKU
- D. The effects of PKU are reversible
Correct Answer: D
Rationale: Phenylketonuria (PKU) is an inherited disorder that increases the levels of phenylalanine (a
building block of proteins) in the blood. If PKU is not treated, phenylalanine can build up
to harmful levels in the body, causing intellectual disability and other serious health
problems. The signs and symptoms of PKU vary from mild to severe. The most severe form
of this disorder is known as classic PKU. Infants with classic PKU appear normal until they
are a few months old. Without treatment, these children develop a permanent intellectual
disability. Seizures, delayed development, behavioral problems, and psychiatric disorders
are also common. Untreated individuals may have a musty or mouse-like odor as a side
effect of excess phenylalanine in the body. Children with classic PKU tend to have lighter skin and hair than unaffected family members and are also likely to have skin disorders
such as eczema. The effects of PKU stay with the infant throughout their life (via Genetic
Home Reference).
A 23-year-old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most likely cause of her symptoms?
- A. Myocardial infarction due to a history of atherosclerosis.
- B. Pulmonary embolism due to deep vein thrombosis (DVT).
- C. Anxiety attacks due to worries about her baby's health.
- D. Congestive heart failure due to fluid overload.
Correct Answer: B
Rationale: In a hospitalized patient on prolonged bed rest, the most likely cause of sudden onset shortness of breath and chest pain is pulmonary embolism. Pregnancy and prolonged inactivity both increase the risk of clot formation in the deep veins of the legs, known as deep vein thrombosis (DVT). These clots can dislodge and travel to the lungs, causing a pulmonary embolism. Myocardial infarction (Choice A) is less likely in a young patient without a significant history of atherosclerosis. Anxiety attacks (Choice C) may present with similar symptoms but are less likely in this context. Congestive heart failure (Choice D) is less probable given the acute onset of symptoms and absence of typical signs like peripheral edema in this case.