Nokea
How should the nurse record the observation of a child with Duchenne muscular dystrophy rising from the floor by walking up the thighs with the hands?
- A. Hand assistance
- B. Leg crawling
- C. Gowers sign
- D. Bright sign
Correct Answer: C
Rationale: The correct term for a child with Duchenne muscular dystrophy rising from the floor by walking up the thighs with the hands is known as the Gowers sign. This maneuver is characteristic of Duchenne muscular dystrophy due to proximal muscle weakness. Choices A, B, and D are incorrect because they do not specifically describe the action of walking up the thighs with the hands, which is a distinctive feature of the Gowers sign.
You may also like to solve these questions
A client with hyperthyroidism is prescribed methimazole. Which adverse effect should the nurse monitor for?
- A. Agranulocytosis
- B. Hypoglycemia
- C. Bradycardia
- D. Hypercalcemia
Correct Answer: A
Rationale: The correct answer is Agranulocytosis. Methimazole, used to treat hyperthyroidism, can lead to agranulocytosis, a severe decrease in white blood cells. This condition increases the risk of infections and requires immediate medical attention. Hypoglycemia (choice B) is not a common adverse effect of methimazole. Bradycardia (choice C) is unlikely as methimazole tends to have minimal effects on heart rate. Hypercalcemia (choice D) is not associated with methimazole use.
Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?
- A. Administer a prescribed sedative.
- B. Reposition the client for comfort.
- C. Apply ice packs to the surgical site.
- D. Instruct the client in the use of the prescribed patient-controlled analgesia (PCA) pump.
Correct Answer: D
Rationale: Instructing the client in the use of the PCA pump is the best initial nursing action for managing severe incisional pain after knee replacement surgery. The PCA pump allows the client to self-administer pain medication effectively, promoting better pain management. Administering a sedative may mask the pain temporarily but doesn't address the root cause. Repositioning the client for comfort or applying ice packs may provide some relief but doesn't address the need for effective pain control as the PCA pump does.
Which pathology is associated with an asthma condition?
- A. Chronic dilation and inflammation of the bronchi.
- B. Recurrent spasms of the airways accompanied by edema and mucus production.
- C. Progressive loss of lung function due to destruction of alveolar walls.
- D. Infection of the lung parenchyma.
Correct Answer: B
Rationale: The correct answer is B: Recurrent spasms of the airways accompanied by edema and mucus production. Asthma is characterized by bronchospasms, inflammation, swelling of the airways, and increased mucus production. This leads to airway constriction, making it difficult to breathe. Choices A, C, and D do not represent the typical pathology seen in asthma. Chronic dilation and inflammation of the bronchi (Choice A) is more characteristic of bronchiectasis, progressive loss of lung function due to destruction of alveolar walls (Choice C) is seen in conditions like emphysema, and infection of the lung parenchyma (Choice D) is more related to conditions like pneumonia.
An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red, and the client reports a burning sensation. What action should the nurse take?
- A. Apply a cool compress to the affected fingers for 20 minutes
- B. Secure a pulse oximeter to monitor the client's oxygen saturation
- C. Report the finding to the healthcare provider as soon as possible
- D. Continue to monitor the fingers until the color returns to normal
Correct Answer: D
Rationale: In primary Raynaud phenomenon, the fingers go through a color sequence of pallor, cyanosis, and then redness when warmed. The burning sensation reported by the client indicates reperfusion. Continuing to monitor the fingers until the color returns to normal is appropriate in this situation as it ensures that the symptoms are resolving without the need for further intervention. Applying a cool compress could exacerbate the symptoms by causing vasoconstriction. Securing a pulse oximeter to monitor oxygen saturation is not necessary in this case as the issue is related to vasospasm rather than oxygenation. Reporting the finding to the healthcare provider is not urgent unless there are signs of complications or the symptoms do not improve with warming.
A 55-year-old client with symptoms of osteoarthritis asks which form of exercise would be most beneficial. What is the best response by the nurse?
- A. Walking.
- B. Running.
- C. Swimming.
- D. Weight lifting.
Correct Answer: C
Rationale: The correct answer is C: 'Swimming.' Swimming is a low-impact exercise that helps maintain joint mobility and reduce pain in clients with osteoarthritis. Unlike running or weight lifting, swimming is gentle on the joints, making it an ideal choice for individuals with osteoarthritis. Walking can be beneficial too, but swimming is often preferred due to its low-impact nature. Running and weight lifting may exacerbate joint pain and should be avoided by individuals with osteoarthritis.