Nokea
Features that would increase suspicion of cerebral palsy at age 9 months include:
- A. Presence of Moro reflex
- B. Abductor spasm
- C. Hand dominance
- D. Grasp reflex
Correct Answer: C
Rationale: Hand dominance at 9 months is a red flag for cerebral palsy. The persistence of primitive reflexes like the Moro and grasp reflexes can also be indicative.
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A male client with a history of asthma reports having episodes of bronchoconstriction and increased mucous production while exercising. Which action should the nurse implement?
- A. Determine if the client is using an inhaler before exercising
- B. Advise the client to avoid all physical activity
- C. Encourage the client to increase fluid intake before exercise
- D. Recommend the client wear a mask while exercising
Correct Answer: A
Rationale: Using an inhaler before exercise can help manage asthma symptoms by preventing bronchoconstriction during physical activity.
Whirlpool' sign in abdominal ultrasonogram is seen in
- A. Duodenal atresia
- B. Midgut volvulus
- C. Intussusception
- D. Anorectal malformation
Correct Answer: B
Rationale: The 'whirlpool' sign on abdominal ultrasound is characteristic of midgut volvulus, indicating twisting of the intestines around the mesenteric vessels.
What are THREE associated echo findings for an infant with wide spaced nipples and a webbed neck?
- A. LV systolic dysfunction
- B. Blunted abdominal aortic Doppler
- C. Bicuspid aortic valve
- D. All of the above
Correct Answer: D
Rationale: These are common echo findings that can be associated with congenital syndromes affecting the heart.
A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client plan of care?
- A. Continuous cardiac monitoring
- B. Perform passive range of motion
- C. Evaluate level of consciousness
- D. Assess lung sounds q4 hours.
Correct Answer: A
Rationale: Electrical injuries can cause cardiac arrhythmias, so continuous cardiac monitoring is critical to detect and manage any life-threatening complications.
Seventy-two hours after cardiac surgery, a young child has a temperature of 101° F. Which action should the nurse take?
- A. Keep child warm with blankets.
- B. Apply a hypothermia blanket.
- C. Record temperature on nurses’ notes.
- D. Report findings to physician.
Correct Answer: D
Rationale: In the first 24 to 48 hours after surgery, the body temperature may increase to 37.7° C (100° F) as part of the inflammatory response to tissue trauma. If the temperature is higher or continues after this period, it is most likely a sign of an infection and immediate investigation is indicated. Blankets should be removed from the child to keep the temperature from increasing. Hypothermia blanket is not indicated for this level of temperature. The temperature should be recorded, but the physician must be notified for evaluation. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time. Symptoms of respiratory distress are avoided by using appropriate technique.