Nokea
The Glasgow coma scale is used to .evaluate the level of consciousness in the neurological and neurological patients. The three assessment factors included in this scale are:
- A. pupil size, response to pain, motor responses
- B. Pupil size, verbal response, motor response
- C. Eye opening, verbal response, motor response
- D. Eye opening, response to pain, motor response J.E, is an 18-year old freshman admitted to the ICU following a motor vehicle accident in which he sustained multiple trauma including a ruptured spleen, myocardial contusion, fractured pelvis, and fractured right femur. He had a mild contusion, but is alert and oriented. His vital signs BP 120/80, pulse 84, respirations 12, and temperature 99 F orally.
Correct Answer: C
Rationale: The Glasgow Coma Scale (GCS) is a neurological scale that is used to assess the level of consciousness in patients. It is based on three factors: eye opening, verbal response, and motor response. Each factor is scored on a scale of 1 to 4 or 6, with a lower total score indicating a lower level of consciousness.
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Biopsy is not usually performed for a child with suspicion of Wilms tumor EXCEPT
- A. age of 2-3 year
- B. signs of inflammation or infection
- C. significant lymph node enlargement radiologically
- D. intratumoral calcification radiologically
Correct Answer: E
Rationale: Presence of intratumoral calcifications may warrant biopsy to rule out other diagnoses.
minutes of birth may be as high as:
- A. 50
- B. 60
- C. 80
- D. 100
Correct Answer: D
Rationale: The number of minutes in an hour is 60. Therefore, the maximum number of minutes at birth can only be 60 minutes in an hour. Since the options provided are all above 60, the highest plausible option is 100 minutes, making option D the correct answer.
An adult has a Hickman type central venous catheter and needs to have blood drawn from it. Which of the following should the nurse do first?
- A. Use sterile technique to assemble supplies needed
- B. Aspirate and discard the first 10 ml of the blood
- C. First flush the catheter with heparinized solution, then withdraw the blood
- D. Remove the cap of the catheter and replace it with a new one
Correct Answer: C
Rationale: Before drawing blood from a central venous catheter like a Hickman type, it is essential to ensure that the catheter is patent and free of any clots. Flushing the catheter with a heparinized solution (to prevent clot formation) before withdrawing blood helps clear the catheter and ensures accurate blood sample collection. Removing clots or obstructions from the catheter is crucial to prevent complications and maintain the catheter's function. Therefore, it is important to first flush the catheter with a heparinized solution before drawing blood from it.
24 hours after undergoing kidney transplantation, a client develops a hyperacute rejection. To correct this problem, the nurse should prepare the client for:
- A. Removal of the transplanted kidney
- B. High-dose IV cyclosporine (Sandimmune) therapy
- C. Bone marrow transplant
- D. Intra-abdominal instillation of methylprednisolone sodium succinate (Solu-Medrol)
Correct Answer: A
Rationale: Hyperacute rejection occurs immediately after transplantation, within minutes to up to 24 hours. It is a rapid and severe rejection reaction that is usually irreversible. It occurs due to pre-existing antibodies against the donor organ. In hyperacute rejection, the transplanted kidney must be removed to prevent further complications and ensure the safety of the patient. Treatment with immunosuppressive medications like cyclosporine or corticosteroids is not effective in this situation. Bone marrow transplant is not indicated in the treatment of hyperacute rejection.
while gently abducting the hips, the nurse feels the femoral head slip into the acetabulum. the nurse documents this finding as a positive:
- A. barlow's test
- B. jackson's sign
- C. ortolani's sign
- D. trendelenburg's sign glomerulonephritis?
Correct Answer: C
Rationale: Ortolani's sign is a physical exam maneuver used to detect congenital hip dislocation in infants. When performing Ortolani's sign, the nurse gently abducts the hips and feels the femoral head slipping back into the acetabulum. This is considered a positive finding and suggests the presence of hip dysplasia. Barlow's test, on the other hand, involves gently adducting the hip to feel for instability and potential dislocation. Jackson's sign is a maneuver for detecting hip dislocation by observing leg length discrepancy. Trendelenburg's sign is a test for hip abductor weakness. Hematuria is the presence of blood in urine and is not related to hip exams or signs.