Nokea
the frontal fontanell is protruding when a child suffering from:
- A. meningitis
- B. hydrocepalus
- C. subdural hematoma
- D. all the answers are correct
Correct Answer: D
Rationale: The protrusion of the frontal fontanelle in a child can be a concerning sign and can be seen in various conditions such as meningitis, hydrocephalus, and subdural hematoma. In meningitis, the inflammation of the meninges can lead to increased intracranial pressure, which may cause the fontanelle to bulge. Hydrocephalus, which is the buildup of fluid in the brain, can also result in the fontanelle being more pronounced. Additionally, a subdural hematoma, which is a collection of blood between the brain and its outermost covering, can lead to pressure on the brain and consequent fontanelle protrusion. Therefore, all the provided choices (A, B, C) are correct as they can lead to the protrusion of the frontal fontanelle in a child.
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During a routine examination of a 10-mo-old male infant, you find a white pupillary reflex of the right eye; the eye movements are normal. You suspect retinoblastoma. Of the following, the BEST confirmatory diagnostic evaluation of this infant is
- A. indirect ophthalmoscopy with slit-lamp examination
- B. examination under general anesthesia by an experienced ophthalmologist
- C. orbital ultrasonography
- D. brain MRI
Correct Answer: B
Rationale: Examination under anesthesia by an experienced ophthalmologist is the gold standard for diagnosing retinoblastoma.
An adolescent tells the school nurse that she is pregnant. Her last menstrual period was 4 months ago. She has not received any medical care. She smokes but denies any other substance use. What is the priority nursing action?
- A. Notify her parents
- B. Refer for prenatal care
- C. Explain the importance of not smoking
- D. Discuss dietary needs for adequate fetal growth
Correct Answer: B
Rationale: The priority nursing action in this situation is to refer the adolescent for prenatal care. Prenatal care is crucial for monitoring the health of both the mother and the baby throughout the pregnancy. This includes assessing for any potential complications, providing appropriate interventions, and ensuring proper support for a healthy pregnancy. It is important for the adolescent to receive medical care as soon as possible to optimize the outcomes for both her and her baby. While notifying her parents, explaining the importance of not smoking, and discussing dietary needs are also important aspects of care, ensuring timely access to prenatal care is the most critical priority in this scenario.
A 3-year-old child from a suburban community presents with vomiting, diarrhea, and blurred vision. Physical examination reveals an afebrile child with pinpoint pupils, salivation, and muscular fasciculations. The child's lawn was treated yesterday for insects. Which of the following tests will establish the correct diagnosis?
- A. Blood-lead level
- B. 24-hour urine mercury level
- C. Plasma cholinesterase level
- D. Urine malathion level
Correct Answer: C
Rationale: The symptoms suggest organophosphate poisoning, which can be confirmed by measuring plasma cholinesterase levels, as organophosphates inhibit this enzyme.
The nurse is assessing a 3-month-old during a well-baby visit. Which of the following findings would warrant the nurse to recommend that the baby have an ultrasound for a possible diagnosis of developmental dysplasia of the hip (DDH)?
- A. Bilateral plantar flexion
- B. Unequal knee heights
- C. Bilateral polydactyly
- D. Positive Babinski test 113
Correct Answer: B
Rationale: Developmental dysplasia of the hip (DDH) is a condition where the hip joint does not develop normally. It is important to detect DDH early in infants as it can lead to long-term hip problems. One of the key physical exam findings that may suggest DDH is unequal knee heights when the infant's legs are flexed. This is known as the Galeazzi sign, and it can indicate hip dysplasia or dislocation. Therefore, if a nurse observes this finding during an assessment of a 3-month-old infant, it would warrant recommending an ultrasound to further evaluate for possible DDH. Bilateral plantar flexion, bilateral polydactyly, and a positive Babinski test are not typically associated with DDH.
As the nurse collects data on a patient, which of the following is a symptom that may be found that the patient with anaphylaxis may be experiencing?
- A. Dermatitis
- B. Sinusitis
- C. Delirium
- D. Wheezing
Correct Answer: D
Rationale: Wheezing is a common symptom of anaphylaxis, along with other signs such as difficulty breathing, chest tightness, coughing, and throat swelling. Wheezing is caused by the constriction of the airways due to the body's extreme immune response to the allergen, leading to difficulty in breathing and wheezing sounds during respiration. It is important for healthcare professionals to recognize wheezing as a symptom of anaphylaxis and respond promptly with appropriate interventions, such as administering epinephrine and providing respiratory support.