Regarding the gross motor skills, a 2-year-old child can
- A. heel-toe walk
- B. balance on each foot 6 sec
- C. walk up and down stairs
- D. balance well on each foot
Correct Answer: C
Rationale: A 2-year-old typically can walk up and down stairs with support.
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Which of the ff should qualify as an abnormal result in a Romberg test?
- A. Hypotension
- B. Swaying, losing balance, or arm drifting
- C. Sneezing and wheezing
- D. Excessive cerumen in the outer ear
Correct Answer: B
Rationale: During a Romberg test, the individual is asked to stand with feet together, arms at sides, and eyes closed. The tester then observes for swaying, losing balance, or arm drifting, which are signs of a positive Romberg test, indicating a potential issue with proprioception or vestibular function. Hypotension (choice A) refers to low blood pressure and is not directly assessed during a Romberg test. Sneezing and wheezing (choice C) are unrelated symptoms. Excessive cerumen in the outer ear (choice D) does not affect the results of a Romberg test focused on balance and proprioception.
A teen asks a nurse, "What is physical dependence in substance abuse?" Which is the correct response by the nurse?
- A. Problem that occurs in conjunction with addiction
- B. Involuntary physiologic response to drug
- C. Culturally defined use of drugs for purposes other than accepted medical purposes
- D. Voluntary behavior based on psychosocial needs
Correct Answer: B
Rationale: Physical dependence in substance abuse refers to the body's physiological adaptation to a drug, leading to the development of withdrawal symptoms when the drug is abruptly stopped or reduced in dosage. This is different from addiction, which involves psychological dependence and compulsive drug-seeking behavior despite harmful consequences. Physical dependence is typically characterized by tolerance (needing higher doses to achieve the same effect) and withdrawal symptoms when the drug is stopped.
What is the Guthrie blood test use to diagnose in the newborn?
- A. Down syndrome
- B. Isoimmunization
- C. PKU
- D. Congenital hypothyroidism (CH)
Correct Answer: C
Rationale: The Guthrie blood test, also known as the newborn screening test, is used to diagnose phenylketonuria (PKU) in newborns. PKU is an inherited metabolic disorder in which the body cannot properly process the amino acid phenylalanine. If left untreated, PKU can lead to intellectual disabilities and other serious health problems. The Guthrie blood test is a simple and effective way to detect PKU early so that treatment can begin promptly to prevent complications.
The most likely cause of her chief complaint this morning is
- A. A decrease in postoperative stress causing poiyuria
- B. The onset of diabetes mellitus, an unusual complication
- C. An expected result of the removal of the pituitary gland
- D. A frequent complication of the hypophysectomy
Correct Answer: D
Rationale: The most likely cause of her chief complaint this morning is a frequent complication of the hypophysectomy. A hypophysectomy is the surgical removal of the pituitary gland. One common complication following a hypophysectomy is diabetes insipidus, characterized by polyuria (excessive urination) and polydipsia (excessive thirst). This occurs because the removal of the pituitary gland can disrupt the regulation of antidiuretic hormone (ADH), which plays a key role in maintaining water balance in the body. Therefore, it is the most likely cause of the patient's chief complaint of polyuria this morning.
The nurse is instructed to perform preoperative preparation for the management of a client with malignant tumors. Which of the ff is the most important factor of the nursing management plan?
- A. Insertion of an ostomy pouch
- B. Assessing the symptoms of peritonitis
- C. Maintaining the integrity of the urinary
- D. Insertion of a nasogastric tube diversion procedure
Correct Answer: B
Rationale: Peritonitis is a serious and potentially life-threatening condition that can occur as a complication of malignant tumors. It is characterized by inflammation of the lining of the abdomen and can result in severe abdominal pain, tenderness, fever, and other symptoms. Prompt assessment of peritonitis symptoms is crucial for early detection and intervention to prevent further complications and improve patient outcomes. Assessing for peritonitis symptoms should be the priority in the nursing management plan to ensure timely and appropriate care for the client with malignant tumors.