Nokea
During an examination, the nurse notices that a female patient has a round "moon"? face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse determines that the patient likely has which condition?
- A. Gigantism
- B. Acromegaly
- C. Cushing syndrome
- D. Marfan syndrome
Correct Answer: C
Rationale: Cushing syndrome is characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and a round, plethoric face (moon face). Excessive catabolism in Cushing syndrome causes muscle wasting, weakness, thin arms and legs, reduced height, and thin, fragile skin with purple abdominal striae, bruising, and acne. Gigantism is characterized by increased height and weight and delayed sexual development, which are not present in the patient. Acromegaly results from excessive growth hormone secretion in adulthood, leading to bone overgrowth in specific areas like the face, head, hands, and feet. Marfan syndrome is an inherited connective tissue disorder characterized by a tall, thin stature and distinct features not seen in this patient. The combination of signs described in the question aligns with the clinical presentation of Cushing syndrome.
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When assessing a 75-year-old patient who has asthma, the nurse notes that the patient assumes a tripod position, leaning forward with arms braced on the chair. How would the nurse interpret these findings?
- A. Interpret that the patient is eager and interested in participating in the interview.
- B. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position.
- C. Interpret that the patient is having difficulty breathing and assist them to a supine position.
- D. Recognize that a tripod position is often used when a patient is having respiratory difficulties.
Correct Answer: D
Rationale: Assuming a tripod position"?leaning forward with arms braced on chair arms"?occurs with chronic pulmonary diseases like asthma. This position helps improve breathing by allowing better use of respiratory muscles. Option A is incorrect because assuming the tripod position is not related to being eager or interested in participating in an interview. Option B is incorrect as abdominal pain is not typically associated with the tripod position in this context. Option C is incorrect as assisting the patient to a supine position would not address the underlying respiratory difficulty indicated by the tripod position. Therefore, the correct interpretation is to recognize that the patient is likely experiencing respiratory difficulties when assuming the tripod position.
When checking for proper blood pressure cuff size, which guideline is correct?
- A. The standard cuff size is appropriate for all sizes.
- B. The length of the rubber bladder should equal 80% of the arm circumference.
- C. The width of the rubber bladder should equal 80% of the arm circumference.
- D. The width of the rubber bladder should equal 40% of the arm circumference.
Correct Answer: D
Rationale: When selecting the correct blood pressure cuff size, it is essential to ensure that the width of the rubber bladder equals 40% of the circumference of the person's arm. This ensures proper fitting and accurate readings. The length of the bladder should actually equal 80% of the arm circumference, not 80% of the width, making choices B and C incorrect. Choice A stating that the standard cuff size is appropriate for all sizes is inaccurate, as using an incorrectly sized cuff can lead to inaccurate blood pressure readings.
A student is late for an appointment and has rushed across campus to the health clinic. How should the nurse proceed?
- A. Allow 5 minutes for the student to relax and rest before checking their vital signs.
- B. Check the blood pressure in both arms, expecting a difference in the readings due to the recent exercise.
- C. Immediately monitor the student's vital signs upon arrival at the clinic and then 5 minutes later, recording any differences.
- D. Check the student's blood pressure in the supine position to provide a more accurate reading and allow the student to relax at the same time.
Correct Answer: A
Rationale: To ensure an accurate blood pressure reading, it is important for the student to be in a relaxed state. Allowing at least a 5-minute rest period helps reduce anxiety and provides a valid blood pressure measurement. Checking the blood pressure in both arms is unnecessary unless there is a specific reason to suspect an issue, and recent exercise should not significantly impact the readings. Monitoring vital signs immediately upon arrival may not yield accurate results due to the rush and anxiety of the student. Checking blood pressure in the supine position is not necessary in this scenario and does not provide a more accurate reading.
You have measured the urinary output of your resident at the end of your 8-hour shift. The output is 25 ounces. What should you do next?
- A. Convert the number of ounces into cc.
- B. Convert the number of ounces into cm.
- C. Immediately report this poor output to the nurse.
- D. Know that 25 ounces of urine is too much in 8 hours.
Correct Answer: A
Rationale: You should convert the number of ounces into cc because cc is the unit of measurement used to record intake and output accurately. This urinary output falls within normal limits, so there is no need to report it immediately to the nurse. It is essential to report urinary outputs of less than 30 cc per hour to detect potential issues early. Converting ounces into centimeters (cm) is not appropriate in this context as cm is a unit of length, not volume. Knowing that 25 ounces of urine is too much in 8 hours is inaccurate as it depends on various factors like fluid intake and individual differences.
On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse's initial response should be to:
- A. Give the client orientation materials and review the unit rules and regulations.
- B. Introduce him/her and accompany the client to the client's room.
- C. Take the client to the day room and introduce him/her to the other clients.
- D. Ask the nursing assistant to get the client's vital signs and complete the admission search.
Correct Answer: B
Rationale: Anxiety is triggered by change that threatens the individual's sense of security. In response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to a calmer, more secure/safe setting. The correct initial response is to introduce the client and accompany them to their room. This approach helps the client feel oriented, safe, and supported. Giving orientation materials or reviewing rules and regulations may overwhelm the client further. Taking the client to the day room and introducing them to other clients could increase anxiety by exposing them to unfamiliar faces. Asking the nursing assistant to get vital signs and complete admission tasks can wait until the client feels more settled and secure in their environment.