Nokea
The first permanent tooth to erupt is
- A. central incisor at 6 years
- B. molar at 6 years
- C. premolar lower canine at 6-7 years
- D. upper canine at 6-7 years
Correct Answer: B
Rationale: The first molar typically erupts at 6 years.
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The age at which the infant can achieve early head control with bobbing motion when pulled to sit is
- A. 2 months
- B. 3 months
- C. 4 months
- D. 6 months
Correct Answer: A
Rationale: Head control typically begins developing around 2 months.
You are evaluating a 2-year-old boy with multiple bruises. Physical examination is unremarkable apart from multiple bruising areas. Lab investigations including coagulation profile are normal. Of the following, bruises that are LEAST likely suggestive of physical abuse is
- A. bruises over the neck
- B. looped extension cord marks on the body
- C. bruises over bony prominences
- D. bruising of the torso
Correct Answer: C
Rationale: Bruises over bony prominences are common in toddlers due to falls and rough play, whereas bruises in unusual locations like the neck or torso are more suspicious for abuse.
Why does the nurse instruct the client to avoid Valsalva maneuvers?
- A. Clients BP will decrease momentarily
- B. Client may lose consciousness
- C. Client may suffer from a myocardial
- D. Clients BP will increase momentarily infarction
Correct Answer: C
Rationale: The nurse instructs the client to avoid Valsalva maneuvers because the client may suffer from a myocardial infarction. The Valsalva maneuver involves forcefully trying to exhale against a closed airway, which can increase intra-thoracic pressure and subsequently increase blood pressure. This can lead to an increased workload on the heart, potentially causing myocardial ischemia or infarction in individuals with underlying heart conditions. Therefore, it is important to avoid Valsalva maneuvers, especially in clients at risk for cardiovascular issues.
A 50-year old male was brought toi the emergency department with a diagnosis of diabetes insipidus. The client had a posterior pituitary tumor. The nursing diagnosis most appropriate for this client is:
- A. fluid volume excess
- B. incontinence, bowel
- C. fluid volume deficit
- D. diarrhea
Correct Answer: C
Rationale: Diabetes insipidus is a condition characterized by excessive thirst and excretion of large amounts of dilute urine, resulting in fluid volume deficit. The posterior pituitary tumor in this case is likely causing decreased secretion of antidiuretic hormone (ADH), leading to the inability of the kidneys to concentrate urine and retain water. This imbalance results in the loss of fluid, leading to dehydration and electrolyte imbalances. Therefore, the most appropriate nursing diagnosis for this client is fluid volume deficit, as the priority is to address the dehydration and restore fluid balance to prevent further complications.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will prescribe diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client does not comply with the recommended treatment, which complication may arise?
- A. Cerebral edema
- B. Severe hyperkalemia
- C. Hypovolemic shock
- D. Tetany
Correct Answer: A
Rationale: Syndrome of inappropriate antidiuretic hormone (SIADH) is characterized by excessive release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia. If a client with SIADH does not comply with the recommended treatment of diuretic therapy and fluid/sodium restriction, there will be continued water retention, resulting in further dilution of sodium levels in the blood (hyponatremia). Severe hyponatremia can lead to cerebral edema, which is a life-threatening complication associated with neurological symptoms such as headache, confusion, seizures, and potentially coma. Therefore, it is important for the client to follow the prescribed treatment to prevent the development of cerebral edema and other serious complications.