Nokea
Nurse Kevin is assessing a newborn for developmental dysplasia of the hip (DDH); he would expect to assess which of the following?
- A. Characteristic limp
- B. Ortolani's sign
- C. Symmetrical gluteal folds
- D. Trendelenburg‘s signs
Correct Answer: B
Rationale: Developmental dysplasia of the hip (DDH) is a condition where the hip joint does not properly form in babies and young children. To assess for DDH, healthcare professionals like Nurse Kevin utilize the Ortolani test. Ortolani's sign is a physical exam maneuver where the healthcare provider will gently manipulate the baby's hips to detect if there is a dislocated hip joint. Specifically, the Ortolani maneuver checks for the presence of a "clunk" as the femoral head relocates into the acetabulum, indicating that the hip joint is dislocated. Therefore, during the assessment of a newborn for DDH, Nurse Kevin would expect to assess for Ortolani's sign as it helps in the diagnosis of developmental dysplasia of the hip.
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An infant has been pronounced dead from sudden infant death syndrome (SIDS) in the emergency department. Which is an appropriate question to ask the parents?
- A. "Did you hear the infant cry out?"
- B. "Why didn't you check on the infant earlier?"
- C. "What time did you find the infant?"
- D. "Was the head buried in a blanket?"
Correct Answer: C
Rationale: This is an appropriate question to ask the parents because determining the time the infant was found is important for investigating the circumstances surrounding the sudden infant death syndrome (SIDS) event. Understanding the timeline can help healthcare providers gather valuable information to determine the cause of death and evaluate any potential contributing factors. This question also allows the healthcare team to better understand the sequence of events leading up to the tragic outcome and offer support to the grieving parents. Asking about the time the infant was found is non-accusatory and focuses on gathering relevant details for the medical evaluation.
Bacterial meningitis alters intracranial physiology, causing:
- A. Cerebral edema
- B. Raised intracranial pressure
- C. Increased permeability of the blood-barrier
- D. All of the above changes
Correct Answer: D
Rationale: Bacterial meningitis can lead to cerebral edema by causing an inflammatory response within the brain tissue. This inflammation can result in the buildup of fluid, leading to edema. Additionally, the inflammatory response can cause an increase in permeability of the blood-brain barrier, allowing substances that are not normally able to cross the barrier to do so. This can lead to further disruption in the balance of fluid within the brain. Finally, the inflammatory response and the buildup of fluid can also result in raised intracranial pressure, which can further exacerbate the physiological changes occurring in the brain. Therefore, all of the above changes - cerebral edema, increased permeability of the blood-brain barrier, and raised intracranial pressure - can be seen in cases of bacterial meningitis.
A 3-year-old boy is hospitalized after falling down the stairs. His mother cries, 'This is all my fault.' Which is the nurse's best response?
- A. Accidents happen; you shouldn't blame yourself.
- B. Falls are one of the most common injuries in this age group.
- C. It might help to install a baby gate on the stairs.
- D. Your son should be proficient at walking down stairs by now.
Correct Answer: B
Rationale: Reassuring the parent that falls are common in young children can help reduce guilt and anxiety.
A 57-year old patient had a right lower lobectomy. The nurse should initiate this action when the patient arrives from the Post Anesthesia Care Unit:
- A. immediately administer pain relief
- B. keep patient in semi-fowler's postion
- C. turn client every hour
- D. notify the family to report pateint's condition
Correct Answer: B
Rationale: After a right lower lobectomy, it is important to keep the patient in a semi-Fowler's position to promote lung expansion and oxygenation. This position helps to reduce pressure on the diaphragm and allows for better lung ventilation. By maintaining the patient in a semi-Fowler's position, it can help prevent complications such as atelectasis and pneumonia postoperatively. It is a crucial nursing intervention to ensure optimal respiratory function and promote recovery after lung surgery.
A seizure characterized by loss of consciousness and tonic spasms of the trunk and extremities rapidly followed by repetitive generalized clonic jerking is classified as:
- A. Focal seizure
- B. Jacksonian seizure
- C. Generalized seizure
- D. Partial seizure
Correct Answer: C
Rationale: The description provided aligns with the characteristics of a generalized seizure. Generalized seizures involve abnormal electrical activity in the entire brain, leading to loss of consciousness and widespread motor symptoms, such as tonic (stiffening) and clonic (jerking) movements affecting both sides of the body. Examples of generalized seizures include tonic-clonic seizures (formerly known as grand mal seizures) where there is a sequence of tonic stiffness followed by clonic jerking. In contrast, focal (partial) seizures originate in a specific area of the brain and may result in localized symptoms before possibly spreading to involve both sides of the brain. Jacksonian seizures specifically refer to focal seizures with motor symptoms that spread in a stepwise fashion, starting from one part of the body.