Nokea
During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?
- A. An old friend with eczema came for a visit
- B. Recently received an influenza immunization
- C. A grandson and his new dog recently visited
- D. Corticosteroid cream was applied to eczema
Correct Answer: C
Rationale: Exposure to new allergens, such as a pet, can trigger eczema flare-ups.
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The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the nurse instruct the client to maintain?
- A. left lateral
- B. Supine, knees flexed
- C. Dorsal recumbent
- D. Knee-chest
Correct Answer: A
Rationale: The left lateral position promotes drainage of the abscess and improves ventilation.
In a cyanotic spell of TOF
- A. Systemic vascular resistance is reduced
- B. Murmur disappear
- C. PO2 is reduced
- D. Right to Left shunt is Increased
Correct Answer: D
Rationale: During a cyanotic spell in Tetralogy of Fallot, there is an increased right-to-left shunting through the ventricular septal defect.
The following are transmitted as autosomal dominant traits:
- A. Congenital spherocytosis
- B. Vitamin D-resistant rickets
- C. CAH
- D. Hereditary haemorrhagic telangiectasia
Correct Answer: D
Rationale: Hereditary haemorrhagic telangiectasia is an autosomal dominant disorder. Congenital spherocytosis and Vitamin D-resistant rickets can also be autosomal dominant, but CAH (Congenital Adrenal Hyperplasia) is typically autosomal recessive.
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take?
- A. Elevate the leg and apply a sandbag to the entrance site.
- B. Increase the flow rate of intravenous fluids.
- C. Assess the color and temperature of the left leg.
- D. Document the finding as the left pedal pulse of +1/4.
Correct Answer: C
Rationale: A weak pedal pulse after cardiac angiography may indicate compromised blood flow. Assessing the color and temperature of the leg helps determine if there is ischemia or other complications.
A 6-year-old child has a systolic blood pressure between the 95th and 99th percentile for age, sex, and height and a diastolic blood pressure between the 90th and the 95th percentile on three separate clinic visits. This child's blood pressure is placed in which classification?
- A. normotensive
- B. pre-hypertensive
- C. stage 1 hypertensive
- D. stage 2 hypertensive
Correct Answer: C
Rationale: Stage 1 hypertensive pressure ranges from the 95th percentile or from 120/80 mm Hg to 5 mm Hg above the 99th percentile for age, sex, and height for either systolic or diastolic pressure.