Nokea
During a physical examination of the 1-month-old, the nurse notes that the infant has blue sclerae. The nurse should further assess for signs and symptoms of which disorder?
- A. Juvenile rheumatoid arthritis (JRA)
- B. Tay-Sachs disease
- C. Duchenne muscular dystrophy (DMD)
- D. Osteogenesis imperfecta (OI)
Correct Answer: D
Rationale: Blue sclerae are a hallmark of osteogenesis imperfecta due to thin connective tissue.
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The nurse is caring for a client with a newly applied plaster cast. How should the nurse touch and move the wet cast?
- A. Use the palms of the hands
- B. Use the fingertips only
- C. Use a towel sling
- D. Touch the cast only on the petals at the edges
Correct Answer: A
Rationale: Using the palms prevents indentations in a wet cast, which could cause skin irritation. Fingertips create indentations, a towel sling is inappropriate, and petaling occurs after drying.
When planning the client's discharge, the nurse must help the client obtain which essential piece of equipment for home care?
- A. A wheelchair
- B. A hospital bed
- C. A raised toilet seat
- D. A mechanical lift
Correct Answer: C
Rationale: A raised toilet seat prevents excessive hip flexion, reducing dislocation risk.
Which of the following evening snacks would the nurse encourage for the client with immobility due to the fractured hip?
- A. An orange
- B. Rice cakes
- C. Peanut butter and celery
- D. Potato chips
Correct Answer: C
Rationale: Peanut butter and celery provide protein and healthy fats, supporting tissue repair and nutrition during immobility. Oranges offer vitamin C but less protein, while rice cakes and potato chips lack substantial nutritional value.
Which assessment finding would the nurse consider a likely adverse effect of the client's methotrexate (Rheumatrex) therapy?
- A. Constipation
- B. Arrhythmia
- C. Mouth sores
- D. Chest pain
Correct Answer: C
Rationale: Mouth sores (stomatitis) are a common adverse effect of methotrexate due to its impact on rapidly dividing cells, like those in the oral mucosa. The other symptoms are less commonly associated.
The nurse is caring for a client six (6) hours postoperative right total knee replacement. Which data should the nurse report to the surgeon?
- A. A total of 100 mL of red drainage in the autotransfusion drainage system.
- B. Pain relief after using the patient-controlled analgesia (PCA) pump.
- C. Cool toes, distal pulses palpable, and pale nailbeds bilaterally.
- D. Urinary output of 60 mL of clear yellow urine in three (3) hours.
Correct Answer: C
Rationale: Cool toes and pale nailbeds suggest vascular compromise, requiring surgeon notification. Expected drainage, pain relief, and low urine output are less urgent.