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During the physical examination of a client for a possible neurologic disorder, how can the nurse examine the client for stiffness and rigidity of the neck?
- A. By positioning the client flat on bed for at least 3 hrs
- B. By moving the head and chin of the client toward the chest
- C. By asking the client to bend and pick up small and large objects on the floor
- D. By introducing a painful stimulus on the neck
Correct Answer: B
Rationale: The nurse can examine the client for stiffness and rigidity of the neck by moving the head and chin of the client toward the chest. This maneuver, known as neck flexion, assesses the resistance and presence of stiffness in the neck muscles. Stiffness and rigidity of the neck muscles may suggest conditions such as meningitis, cervical dystonia, or other neurologic disorders. It is important for the nurse to perform this examination maneuver carefully to avoid causing discomfort or injury to the client.
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A client with primary diabetes insipidus is ready for discharge on desmopressin (DDAVP). Which instruction should the nurse provide?
- A. "Administer desmopressin while the suspension is cold."
- B. "Your condition isn't chronic, so you won't need to wear a medical identification bracelet."
- C. "You may not be able to use desmopressin nasally if you have nasal discharge or blockage."
- D. "You won't need to monitor your fluid intake and output after you start taking desmopressin."
Correct Answer: C
Rationale: It is important for the nurse to instruct the client that they may not be able to use desmopressin nasally if they have nasal discharge or blockage. This is because nasal absorption is critical for the effectiveness of desmopressin, and any nasal issues may hinder proper absorption. If the client experiences nasal discharge or blockage, an alternative route for administering desmopressin may need to be considered, such as oral or injectable forms. This instruction is essential to ensure the client receives the medication effectively and manages their condition appropriately.
In pediatric rhabdomyosarcoma, stages are dependent on primary site whether favorable or unfavorable. Which of the following sites of involvement is considered unfavorable?
- A. vagina
- B. uterus
- C. testis
- D. paranasal sinuses
Correct Answer: D
Rationale: Paranasal sinuses are considered unfavorable sites in rhabdomyosarcoma staging.
A nurse is preparing to accompany a medical mission's team to a third world country. Marasmus is seen frequently in children 6 months to 2 years in this country. Which symptoms should the nurse expect for this condition?
- A. Loose, wrinkled skin
- B. Edematous skin
- C. Depigmentation of the skin
- D. Dermatoses
Correct Answer: A
Rationale: Marasmus is a form of severe malnutrition characterized by a significant deficiency in calories and protein intake. Symptoms of marasmus include severe wasting of muscle and fat stores, giving the appearance of loose, wrinkled skin due to the loss of subcutaneous fat. Other symptoms may include lethargy, irritability, delayed growth and development, and weakened immune function. Edematous skin is more commonly associated with kwashiorkor, another form of severe malnutrition characterized by protein deficiency with adequate caloric intake. Depigmentation of the skin and dermatoses are not typical symptoms of marasmus.
A client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?
- A. Cool, clammy skin
- B. Increased urine osmolarity
- C. Distended neck veins
- D. serum sodium level
Correct Answer: B
Rationale: Increased urine osmolarity would best support the nursing diagnosis of Deficient fluid volume in a client with hyperglycemia. Hyperglycemia can lead to osmotic diuresis, where the body excretes excessive amounts of water to help eliminate glucose. This results in concentrated urine with a higher osmolarity. A high urine osmolarity indicates that the kidneys are conserving water due to decreased fluid volume in the body, supporting the diagnosis of Deficient fluid volume. The other assessment findings (cool, clammy skin, distended neck veins, serum sodium level) are not specific to the diagnosis of Deficient fluid volume in this context.
A 2-month-old premature infant born at 30 weeks gestation is scheduled for an inguinal hernia repair. Which of the following preoperative findings would BEST predict an increased risk of postoperative apnea?
- A. Hemoglobin 7 gm/dL
- B. Glucose 61 mg/dL
- C. Room air SpO2 92%
- D. N/A
Correct Answer: A
Rationale: Low hemoglobin levels in a premature infant can increase the risk of postoperative apnea due to reduced oxygen-carrying capacity.