Nokea
Nurse Mariane is caring for an infant with spina bifida. Which technique is most important in recognizing possible hydrocephalus?
- A. Measuring head circumference
- B. Obtaining skull X-ray
- C. Performing a lumbar puncture
- D. Magnetic resonance imaging (MRI)
Correct Answer: A
Rationale: Measuring head circumference is a non-invasive way to monitor for hydrocephalus, a common complication of spina bifida.
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In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin?
- A. Black ulcers and dependent rubor
- B. Irregular ulcer shapes and severe edema
- C. Absent pedal pulses and shiny skin
- D. Hairless lower extremities and cool feet
Correct Answer: B
Rationale: Venous ulcers are typically irregular in shape and associated with severe edema, while arterial ulcers are more likely to present with absent pulses and cool extremities.
Severe pulmonary valve stenosis is defined as a peak gradient of
- A. >40 mm Hg
- B. >45 mm Hg
- C. >50 mm Hg
- D. >55 mm Hg
Correct Answer: C
Rationale: Severe pulmonary valve stenosis is generally defined as a peak gradient >50 mm Hg.
Uncommon complications of severe falciparum malaria are:
- A. Stroke
- B. Anaemia
- C. Hepatitis
- D. Jaundice
Correct Answer: A
Rationale: The correct answer is A because stroke is an uncommon complication of severe falciparum malaria. The other options (b-e) are more common complications.
The nurse is conducting a staff in-service on congenital heart defects. Which structural defect constitutes tetralogy of Fallot?
- A. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
- B. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
- C. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
- D. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy
Correct Answer: A
Rationale: Tetralogy of Fallot has these four characteristics: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. There is pulmonic stenosis but not atrial stenosis in tetralogy of Fallot. Right ventricular hypertrophy, not left ventricular hypertrophy, is present in tetralogy of Fallot. Tetralogy of Fallot has right ventricular hypertrophy, not left ventricular hypertrophy, and an atrial septal defect, not aortic hypertrophy.
A nurse is preparing to administer an angiotensin-converting enzyme (ACE) inhibitor. Which drug should the nurse administer?
- A. Captopril (Capoten)
- B. Furosemide (Lasix)
- C. Spironolactone (Aldactone)
- D. Chlorothiazide (Diuril)
Correct Answer: A
Rationale: Captopril is an ACE inhibitor. Furosemide is a loop diuretic. Spironolactone blocks the action of aldosterone. Chlorothiazide works on the distal tubules.