Nokea
An older female client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. To determine if the client is experiencing any long-term complication of DM, which assessments should the nurse obtain?
- A. Serum creatinine and blood urea nitrogen (BUN)
- B. Sensation in feet and legs
- C. Skin condition of lower extremities
- D. Visual acuity
Correct Answer: B
Rationale: These assessments are crucial for detecting complications such as neuropathy, nephropathy, and retinopathy.
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A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?
- A. Obtain oxygen saturation level
- B. Encourage incentive spirometry
- C. Assess lower extremity circulation
- D. Administer PRN oral antipyretic
Correct Answer: D
Rationale: Administering an antipyretic addresses the fever, which is a priority in this client to prevent further complications.
Fetal distress is indicated by:
- A. Meconium staining of liquor
- B. Arrhythmias
- C. Tachycardia
- D. Bradycardia
Correct Answer: D
Rationale: The correct answer is D because bradycardia is a key indicator of fetal distress. The other options (a, b, c, e) are less specific or not primary indicators.
Hypertrophic obstructive cardiomyopathy
- A. Causes LV outflow tract obstruction
- B. Occurs after adenoviral infection
- C. Commonly occurs in infancy
- D. Double apical impulse
Correct Answer: A
Rationale: Hypertrophic obstructive cardiomyopathy primarily causes left ventricular outflow tract obstruction.
Functional causes of opening Snap (either due to swift opening of AV valve or due to excess flow across the valve) is seen in all, except
- A. Mitral regurgitation
- B. Ventricular septal defect
- C. Atrial septal defect
- D. First degree AV block
Correct Answer: D
Rationale: First degree AV block is not typically associated with an opening snap.
Recognised features of brucellosis include:
- A. Osteomyelitis
- B. Liver granuloma
- C. Pericarditis
- D. Splenomegaly
Correct Answer: D
Rationale: Splenomegaly