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Mrs. Santos, a 75-year old patient with type II diabetes is in emergency department with signs of hyperglycemic, hyperosmolar nonketotic (HHNK) coma. What assessment finding should the nurse expect?
- A. Fruity odor of the breath
- B. shallow, deep respirations
- C. severe dehydration
- D. profuse sweating
Correct Answer: C
Rationale: In a patient with hyperglycemic, hyperosmolar nonketotic coma (HHNK), the high blood glucose levels lead to osmotic diuresis, causing excessive urination and subsequent dehydration. Dehydration can manifest as symptoms such as dry mucous membranes, poor skin turgor, decreased urine output, increased heart rate, and low blood pressure. Therefore, the nurse should expect to find signs of severe dehydration in a patient with HHNK coma. The other options listed are not typical assessment findings associated with HHNK coma.
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A 7 year old boy came to OPD with history of difficulty in rising up from sitting position. Examination reveals hypertrophy of calf muscles with trendelenburg gait. The most likely diagnosis is:
- A. Becker's muscular dystrophy
- B. Duchenne muscular dystrophy
- C. Myotonic muscular dystrophy
- D. Cerebral palsy
Correct Answer: B
Rationale: Duchenne muscular dystrophy typically presents in early childhood with difficulty rising from a seated position (Gower's sign), calf muscle hypertrophy, and Trendelenburg gait.
What is an important nursing responsibility when dealing with a family experiencing the loss of an infant from sudden infant death syndrome (SIDS)?
- A. Explain how SIDS could have been predicted and prevented. TestBankWorld.org
- B. Interview parents in depth concerning the circumstances surrounding the child's death.
- C. Discourage parents from making a last visit with the infant.
- D. Make a follow-up home visit to parents as soon as possible after the child's death.
Correct Answer: D
Rationale: One of the most important nursing responsibilities when dealing with a family experiencing the loss of an infant from sudden infant death syndrome (SIDS) is to provide ongoing support and care to the grieving parents. Making a follow-up home visit as soon as possible after the child's death allows the nurse to offer emotional support, assess the parents' well-being, provide information on coping strategies, and refer them to appropriate resources such as counseling services or support groups. This visit also enables the nurse to address any questions or concerns the parents may have, validate their feelings of grief, and help them navigate the difficult grieving process. By being present and available to the family during this challenging time, the nurse can help them feel supported and cared for as they cope with the tragic loss of their infant.
Which of the following signs indicates to the nurse that digoxin (Lanoxin) has been effective for a patient?
- A. Urine output decreases
- B. Heart rate higher than 95
- C. Urine output increases
- D. Heart rate lower than 50
Correct Answer: C
Rationale: Digoxin is a medication commonly used to treat heart failure and certain types of irregular heart rhythms. One of the therapeutic effects of digoxin is an improvement in cardiac output, leading to better tissue perfusion. As the heart's pumping ability improves, blood flow to the kidneys also increases, resulting in an increase in urine output. Therefore, an increase in urine output is a positive indication that digoxin is effective for the patient. Monitoring urine output can be a valuable way for nurses to assess the response to digoxin therapy and the overall cardiac function of the patient.
Which of the following is the most common permanent disability in childhood?
- A. Scoliosis
- B. Muscular dystrophy
- C. Cerebral palsy
- D. Developmental dysplasia of the hip (DDH)
Correct Answer: C
Rationale: Cerebral palsy is the most common permanent disability in childhood among the options provided. It is a group of disorders that affect movement and muscle coordination due to damage or abnormal development in the brain. Cerebral palsy can occur before, during, or shortly after birth, and it is a lifelong condition that impacts a child's ability to move, maintain balance, and posture. Scoliosis, muscular dystrophy, and developmental dysplasia of the hip (DDH) are also significant conditions that can lead to disabilities in children, but they are not as prevalent as cerebral palsy in terms of permanent disabilities in childhood.
After surgery the nurse notes that the patient's urine is dark amber and concentrated. Which of the following does the nurse understand may be the reason for this?
- A. The sympathetic nervous system saves fluid in response to stress of surgery.
- B. The sympathetic nervous system diereses fluid in response to stress of surgery.
- C. The parasympathetic nervous system saves fluid in response to stress of surgery.
- D. The parasympathetic nervous system diereses fluid in response to stress of surgery.
Correct Answer: A
Rationale: The sympathetic nervous system saves fluid in response to the stress of surgery, leading to the urine becoming dark amber and concentrated. During stressful events such as surgery, the body activates the sympathetic nervous system as part of the fight-or-flight response. One of the functions of the sympathetic nervous system in this situation is to conserve fluids in the body by reducing urine output. This results in more concentrated urine, often appearing dark amber in color. Conversely, the parasympathetic nervous system is not typically involved in conserving fluid during stress responses.