The following are suggestive of abnormal language development:
- A. Not localising sound at 4 months of age
- B. No response to human words at 6 weeks
- C. Not understanding 'no' at 18 months of age
- D. Does not move to music at 2 years of age
Correct Answer: C
Rationale: Failure to understand simple commands like 'no' by 18 months is a red flag for abnormal language development.
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A client with draining skin lesions of the lower extremity is admitted with possible Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing interventions should the nurse include in the plan of care?
- A. Institute contact precautions for staff and visitors.
- B. Send wound drainage for culture and sensitivity.
- C. Monitor the client's white blood cell count.
- D. Administer broad-spectrum antibiotics before obtaining cultures.
Correct Answer: B
Rationale: MRSA requires contact precautions to prevent spread, culture and sensitivity testing is necessary to identify the specific organism, and WBC count should be monitored to assess for infection.
Regarding cranial nerves:
- A. Meningioma of the olfactory groove may cause unilateral anosmia
- B. Lesion in the geniculate ganglion produces hyperacusis
- C. Frontalis muscle is spared in lower motor neuron facial palsy
- D. In oculomotor palsy, pupillary sparing occurs in early stages of external compression of the nerve by a tumour
Correct Answer: A
Rationale: Meningioma affecting the olfactory groove can compress the olfactory nerve, leading to unilateral anosmia.
The nurse is preparing to administer a dose of digoxin (Lanoxin) to a child in heart failure (HF). Which is a beneficial effect of administering digoxin (Lanoxin)?
- A. It decreases edema.
- B. It decreases cardiac output.
- C. It increases heart size.
- D. It increases venous pressure.
Correct Answer: A
Rationale: Digoxin has a rapid onset and is useful for increasing cardiac output, decreasing venous pressure, and, as a result, decreasing edema. Cardiac output is increased by digoxin. Heart size and venous pressure are decreased by digoxin.
Duchenne muscular dystrophy:
- A. Has an association with malignant hyperpyrexia
- B. Is a reason for never running properly
- C. Is better diagnosed with muscle biopsy than gene probe
- D. Is associated with speech delay
Correct Answer: D
Rationale: Duchenne muscular dystrophy is associated with speech delay due to progressive muscle weakness, including facial muscles affecting speech.
A client with acute renal injury (AKI) who weighs 50 kg and has a potassium level of 6.7 mEq/L (6.7 mmol/l) is admitted to the hospital. Which prescribed medication should the nurse administer first?
- A. Sevelamer (RenaGel) one tablet PO.
- B. Epoetin alfa, recombinant (Epogen) 2,500 units SUBQ
- C. Sodium polystyrene (Kayexalate) 15 grams PO
- D. Calcium acetate (Phos-Lo) one tablet PO
Correct Answer: C
Rationale: Sodium polystyrene (Kayexalate) helps remove excess potassium, which is the priority concern in AKI with elevated potassium.
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