In embryonic period, formation of all of the following occur by the given time EXCEPT
- A. 8 days - blastocyst formation
- B. 6 weeks - ectoderm formation
- C. 8 weeks - crown-rump length about 3 cm
- D. 10 weeks - endoderm formation
Correct Answer: D
Rationale: Endoderm formation occurs much earlier than 10 weeks in the embryonic period.
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A client with serum glucose level of 618mg/dl is admitted to the facility. He's awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6F (38.1C), heart rate of 116 beats/min, and blood pressure of 108/70mHg. Based on these assessment findings, which nursing diagnosis take highest priority?
- A. Deficient volume related to osmotic diuresis
- B. Decreased cardiac output related to elevated heart rate
- C. Imbalanced nutrition: Less than body requirements related to insulin deficiency
- D. Ineffective thermoregulation related to dehydration
Correct Answer: A
Rationale: The client's serum glucose level of 618mg/dl is indicative of severe hyperglycemia, likely due to uncontrolled diabetes mellitus. The client's presentation with hot dry skin, elevated heart rate, and low blood pressure suggests dehydration as a result of osmotic diuresis, which occurs in an attempt to excrete excess glucose. With an elevated heart rate and low blood pressure, it is essential to address the deficient volume to prevent further complications such as hypovolemic shock. Rehydration and fluid replacement are crucial interventions to help restore the client's fluid balance and prevent hemodynamic instability. Addressing the deficient volume related to osmotic diuresis should take the highest priority in this case.
A client with HIV has been prescribed anti viral medications. What instructions related to administration of medications should the nurse give such a client?
- A. Comply with the timing of antiviral medication around meals
- B. Avoid exposure to harsh sunlight for about 2hrs after taking the medication
- C. Have the medications with plenty of fruit juice
- D. Have an increased dose of the medications if the symptoms worsen
Correct Answer: A
Rationale: The nurse should instruct the client to comply with the timing of antiviral medication around meals. Taking some antiviral medications with food can help reduce gastrointestinal side effects. Certain medications may be more effective when taken with food, while others may need to be taken on an empty stomach. It is essential for the client to follow the specific instructions given by their healthcare provider to ensure the optimal effectiveness of the antiviral medications.
Which is true of a Wilms tumor? (Select all that apply.)
- A. It is also referred to as neuroblastoma.
- B. It is most commonly seen between the ages of 2 and 5 years.
- C. It can occur on its own or be associated with congenital anomalies.
- D. It is a slow-growing tumor.
Correct Answer: C
Rationale: Wilms tumor typically occurs in children aged 2-5 years and may be associated with congenital anomalies. It is not the same as neuroblastoma, and its prognosis is generally good with treatment.
The nurse is teaching a class about breast self-examinations. A client asks if the she should have an annual mammogram. According to the American Cancer Society, how should the nurse respond?
- A. All women over age 30 should have an annual mammogram.
- B. All women over age 40 should have an annual mammogram.
- C. Any woman over age 20 whose mother had breast cancer should have an annual mammogram.
- D. Any woman who feels she is at risk for breast cancer should have an annual mammogram.
Correct Answer: B
Rationale: According to the American Cancer Society, they recommend that all women aged 40 to 44 should have the choice to start annual mammograms if they wish to do so. For women aged 45 to 54, it is recommended to have an annual mammogram. For women aged 55 and older, they can switch to mammograms every two years or continue with annual screenings. Mammograms are an important screening tool for detecting breast cancer early, especially in women over the age of 40 when the risk of developing breast cancer increases.
Failure to thrive (FTT) is a descriptive term given to malnourished infants and young children who fail to meet expected standards of growth. Of the following, the growth parameter that is usually not affected by malnutrition is
- A. weight
- B. height
- C. weight for height ratio
- D. head circumference
Correct Answer: D
Rationale: Head circumference is less likely to be affected by short-term malnutrition because brain growth is prioritized during infancy and early childhood.
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