Nokea
Inability to do which of the following in a 20-month child is cause for concern?
- A. Speak in clear two to three word phrases
- B. Walk unaided
- C. Kick a ball
- D. Build a tower of 8 blocks
Correct Answer: B
Rationale: Inability to walk unaided by 20 months is a red flag for developmental delay. Other skills are more variable and less concerning if delayed.
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A 2-month-old male presents with tachycardia, dyspnea, tachypnea, and a gallop rhythm with no heart murmur. He was perfectly well until 1 day prior to the episode. The physical examination reveals a heart rate of 235, a temperature of 37.8°C, and a normal blood pressure with warm, well-perfused extremities. The most likely diagnosis is
- A. sepsis
- B. supraventricular tachycardia
- C. ingestion
- D. ventricular tachycardia
Correct Answer: B
Rationale: Supraventricular tachycardia can cause rapid heart rates and heart failure in infants.
A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?
- A. Teach the client techniques for performing intermittent catheterization
- B. Increase the client's fluid intake to promote frequent urination.
- C. Suggest the use of incontinence pads for comfort
- D. Administer anticholinergic medications to enhance bladder function.
Correct Answer: A
Rationale: Intermittent catheterization helps manage urinary retention and prevents complications like urinary tract infections.
Which statement by a parent of an infant with congestive heart failure (CHF) who is being sent home on digoxin indicates the need for further education?
- A. I will give the medication at regular 12-hour intervals.
- B. If he vomits, I will not give a make-up dose.
- C. If I miss a dose, I will not give an extra dose.
- D. I will mix the digoxin in some formula to make it taste better.
Correct Answer: D
Rationale: Mixing digoxin with formula can lead to incomplete ingestion and inadequate dosing. Digoxin must be given in its entirety at the prescribed times.
What does the nurse explain that a ventricular septal defect will allow?
- A. Blood to shunt left to right, causing increased pulmonary flow and no cyanosis
- B. Blood to shunt right to left, causing decreased pulmonary flow and cyanosis
- C. No shunting because of high pressure in the left ventricle
- D. Increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume
Correct Answer: A
Rationale: Pulmonary blood flow is increased when a ventricular septal defect exists. The blood shifts from left to right because of the higher pressure in the left ventricle. This particular shift does not cause cyanosis.
The severity of symptoms of Ebstein anomaly and the degree of cyanosis are high and depend on the extent of
- A. displacement of the tricuspid valve
- B. cardiac dysrhythmias
- C. atrial right-to-left shunt
- D. pulmonary vascular resistance
Correct Answer: A
Rationale: Displacement of the tricuspid valve is a key determinant of symptom severity in Ebstein anomaly.