Nokea
During an adolescent examination, the nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?
- A. Spinal flexibility
- B. Leg length disparity
- C. Hypostatic blood pressure
- D. Scoliosis
Correct Answer: D
Rationale: The correct answer is scoliosis. During the assessment for scoliosis, the nurse asks the adolescent to bend forward at the waist with arms hanging freely to observe for any lateral deviation of the spine, uneven rib levels, or asymmetry. This assessment is a routine part of an adolescent examination, especially in females, as scoliosis is more common in this population. Choices A, B, and C are incorrect. Spinal flexibility is usually assessed through different maneuvers, leg length disparity is evaluated by measuring the length of the legs, and hypostatic blood pressure refers to a decrease in blood pressure due to immobility.
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A patient with Addison's disease asks a nurse for nutrition and diet advice. Which of the following diet modifications is not recommended?
- A. A diet high in grains
- B. A diet with adequate caloric intake
- C. A high protein diet
- D. A restricted sodium diet
Correct Answer: D
Rationale: For a patient with Addison's disease, a restricted sodium diet is not recommended. These patients require normal dietary sodium to prevent excess fluid loss. Patients with primary adrenal insufficiency (Addison disease) should have ample access to salt because of the salt wasting that occurs if their condition is untreated. Therefore, a diet high in grains, a diet with adequate caloric intake, and a high protein diet are all recommended for patients with Addison's disease to support their nutritional needs and overall health. However, restricting sodium can be detrimental for these patients due to the nature of their condition.
If you are caring for a patient of the Hindu culture, what may you anticipate regarding visitors?
- A. Limited visitors, respectful of privacy
- B. Family members only
- C. Large number of visitors/community support
- D. None of the above
Correct Answer: C
Rationale: In Hindu culture, there is a strong sense of community and support. It is common for a patient to receive a large number of visitors, indicative of the community coming together to provide emotional and practical support. This support network is crucial for the patient's well-being and healing process. Option A, limited visitors, is incorrect as the Hindu culture values community involvement. Option B, family members only, is incorrect as the support network extends beyond just family. Option D, none of the above, is incorrect as the Hindu culture typically involves community support and a significant number of visitors.
A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?
- A. High Fowler's
- B. Supine
- C. Left lateral
- D. Low Fowler's
Correct Answer: A
Rationale: The correct answer is "High Fowler's" position. Sitting in a chair or resting in a bed in a high Fowler's position decreases the cardiac workload and facilitates breathing. This position helps reduce the work of breathing and promotes optimal lung expansion, making it easier for the client to breathe. Supine position (choice B) is lying flat on the back and may not be ideal for clients with congestive heart failure as it can increase pressure on the heart. Left lateral position (choice C) is commonly used for promoting circulation in clients with certain conditions but is not the most appropriate for congestive heart failure. Low Fowler's position (choice D) is not recommended as it does not provide the same benefits in terms of reducing cardiac workload and easing breathing as the high Fowler's position.
A 32-year-old pregnant woman comes to the clinic for her prenatal visit. The nurse gathers data about her obstetric history, which includes 3-year-old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information?
- A. G4 T1 P0 A1 L2
- B. G3 T1 P0 A1 L2
- C. G3 T0 P1 A1 L2
- D. G4 T0 P1 A1 L2
Correct Answer: D
Rationale: The correct answer is G4 T1 P0 A1 L2. This documentation accurately represents the woman's obstetric history.
G4: She is currently pregnant (1), has twins (1), and had a miscarriage (1), totaling four pregnancies.
T1: She has had one pregnancy that resulted in the birth of her twins at term.
P0: She has not had any preterm births.
A1: She had one miscarriage at 12 weeks gestation.
L2: She has two living children (the twins). Therefore, the correct documentation reflects all aspects of her obstetric history as provided.
A patient who has been diagnosed with vasospastic disorder (Raynaud's disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?
- A. An adolescent male
- B. An elderly woman
- C. A young woman
- D. An elderly man
Correct Answer: C
Rationale: The correct answer is 'A young woman.' Raynaud's disease is most common in young women and is often associated with rheumatologic disorders like lupus and rheumatoid arthritis. This disorder involves vasospasm of the arteries, leading to reduced blood flow to the fingers and toes. Typically, Raynaud's affects the fingers, and in some cases, it can affect the toes. Only rarely does it involve other body parts such as the nose, ears, nipples, and lips. Choices B, C, and D are less likely as Raynaud's disease predominantly affects young women, although it can occur in other demographic groups as well.