Nokea
Regarding cafe-au-lait spots:
- A. They can be normal findings
- B. They are found in tuberous sclerosis
- C. When present in a child, > 4 spots each > 0.5 cm, is diagnostic of neurofibromatosis type II
- D. Typical appearance in neurofibromatosis is of a smooth border
Correct Answer: A
Rationale: Cafe-au-lait spots can be a normal variant and do not always indicate an underlying pathology.
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In which of the following valve lesions, Dimensionless Index (DI) is used as an echocardiographic parameter to assess the severity of the lesion?
- A. Aortic stenosis
- B. Aortic regurgitation
- C. Mitral regurgitation
- D. Mitral stenosis
Correct Answer: A
Rationale: Dimensionless Index (DI) is used to assess the severity of aortic stenosis.
An older adult man recently diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. The nurse observes the client sitting upright and leaning over the bedside table, using accessory muscles to assist in breathing. What action should the nurse take?
- A. Assist the client to a high Fowler's position in bed
- B. Observe the client for the presence of a barrel chest
- C. Prepare to transfer the client to a critical care unit
- D. Instruct the client in pursed lip breathing techniques
Correct Answer: D
Rationale: Pursed lip breathing helps reduce dyspnea and improves oxygenation in clients with COPD.
An older woman who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and she only eats half of the food on her meal tray. Her family expresses concern about her nutritional status. How should the nurse respond to the family's concern?
- A. Encourage the family to offer to feed the client when she does not eat her entire meal.
- B. Suggest that the family bring foods from home that the client enjoys
- C. Explain that weight loss will be reversed after the acute phase of the stroke has ended.
- D. Demonstrate the use of visual scanning during meals to the client and family.
Correct Answer: D
Rationale: Visual scanning techniques help the client become aware of the entire meal tray, improving food intake and addressing the family's concerns.
While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. what is the etiology of this problem?
- A. Irritation of nerve endings
- B. Diminished blood flow
- C. Ischemic tissue changes
- D. Compression of a nerve
Correct Answer: D
Rationale: Carpal tunnel syndrome is caused by compression of the median nerve, leading to pain and other symptoms.
Family discharge teaching has been effective when the parent of a toddler diagnosed with Kawasaki disease (KD) states:
- A. The arthritis in her knees is permanent. She will need knee replacements.
- B. I will give her diphenhydramine (Benadryl) for her peeling palms and soles of her feet.
- C. I know she will be irritable for 2 months after her symptoms start.
- D. I will continue with high doses of Tylenol for her inflammation.
Correct Answer: C
Rationale: This statement indicates the parent understands that irritability may persist for about 2 months after symptom onset in KD.