Nokea
Bryce is a child diagnosed with coarctation of aorta. While assessing him, Nurse Zach would expect to find which of the following?
- A. Squatting posture
- B. Absent or diminished femoral pulses
- C. Severe cyanosis at birth
- D. Cyanotic ("tet") episodes 46
Correct Answer: B
Rationale: Coarctation of the aorta is a congenital heart defect where there is a narrowing of the aorta, usually near the insertion of the ductus arteriosus. This narrowing can lead to decreased blood flow to the lower body. A common finding in a child with coarctation of the aorta is absent or diminished femoral pulses due to the obstruction of blood flow through the narrowed aorta. Other symptoms may include high blood pressure in the arms, weak lower body pulses, and heart murmur. Squatting posture, severe cyanosis at birth, and cyanotic ("tet") episodes are not typically associated with coarctation of the aorta.
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Use of condoms of those found to be infected with HIV
- A. 1 & 3
- B. 3 & 4
- C. 2 & 3 SITUATION; Mr. Baldo , 36 years old patient complaints of fatigue, weight loss, and low-grade fever. He also has pa in his fingers, elbows, and ankles.
Correct Answer: B
Rationale: In the given scenario involving Mr. Baldo presenting with symptoms of fatigue, weight loss, low-grade fever, and joint pain in fingers, elbows, and ankles, it is suggested that he may potentially have rheumatoid arthritis. Therefore, options 3 and 4 are the correct choices. Option 3 mentions the administration of NSAIDs (Nonsteroidal Anti-Inflammatory Drugs) for pain management, which is a common treatment approach for rheumatoid arthritis to help reduce inflammation and manage pain. Option 4 suggests consulting a rheumatologist for further evaluation and management, which is crucial in determining the appropriate diagnosis and treatment plan for Mr. Baldo's condition.
The parents of a 3-month-old infant report that their infant sleeps supine (face up) but is often prone (face down) while awake. What knowledge should the nurse's response should be based?
- A. Unacceptable because of the risk of sudden infant death syndrome (SIDS)
- B. Unacceptable because it does not encourage achievement of developmental milestones
- C. Acceptable to encourage fine motor development
- D. Acceptable to encourage head control and turning over
Correct Answer: D
Rationale: The correct knowledge that the nurse's response should be based on is that it is acceptable to encourage head control and turning over. At 3 months of age, encouraging the infant to be prone while awake can help promote the development of head control, neck strength, and eventually facilitate the ability to turn over. This practice is considered safe and beneficial for infants within the appropriate age range, as long as the infant is supervised during the awake period. It is important to promote safe sleep practices for infants to reduce the risk of Sudden Infant Death Syndrome (SIDS), but allowing supervised tummy time for an awake infant is beneficial for their motor development.
A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:
- A. Weight gain
- B. Respiratory acidosis
- C. Fine motor tremors
- D. Bilateral hearing loss
Correct Answer: D
Rationale: Prolonged aspirin therapy can lead to a rare side effect known as aspirin-induced hearing loss, which manifests as bilateral hearing loss. This adverse reaction is typically associated with higher doses of aspirin and longer durations of use. It is important for healthcare providers to monitor for signs of hearing loss in patients receiving long-term aspirin therapy, especially those with rheumatoid arthritis or other inflammatory conditions, to prevent irreversible damage to the hearing. Weight gain, respiratory acidosis, and fine motor tremors are not commonly associated with prolonged aspirin therapy.
A 15-month-old toddler was able to do all the following EXCEPT
- A. walks alone
- B. makes tower of 3 cubes
- C. inserts raisin in a bottle
- D. responds to his/her name
Correct Answer: D
Rationale: Responding to name usually occurs earlier, around 6-9 months.
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.