Nokea
The LPN is performing an assessment on a 4-day-old 8-pound, 6-ounce newborn with a head circumference of 33 cm. Given this information, what would the nurse expect the child's chest circumference to be?
- A. about 31 cm
- B. about 36 cm
- C. about 29 cm
- D. about 33 cm
Correct Answer: A
Rationale: In newborns, the head circumference should be 2 cm to 3 cm larger than the chest circumference. Note: Due to molding that occurs during the birth process, the head and chest measurement may be nearly equal during the first 48 hours after birth.
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You are caring for a 78-year-old woman who is wondering why she was diagnosed with glaucoma. Although she has several risk factors, which of these is not one of them?
- A. age
- B. blood pressure reading of 143/89
- C. Mexican-American heritage
- D. 20/80 vision
Correct Answer: D
Rationale: Age over 60 and Mexican-American ancestry are both risk factors for glaucoma. Elevated blood pressure also is a risk factor as it can cause optic nerve damage. 20/80 vision, while poor, is not a causal factor for glaucoma.
The nurse is assessing the client with herpes zoster. The nurse determines that acyclovir is an effective treatment when which finding is noted?
- A. Drying and crusting of genital lesions
- B. Crusting and healing of vesicular skin lesions
- C. Urticaria decreased and pruritus relieved
- D. Decrease in intensity of chicken pox lesions
Correct Answer: B
Rationale: A: Drying and crusting of genital lesions would indicate acyclovir's effectiveness for treating genital herpes, not herpes zoster. B: Herpes zoster produces painful vesicular skin eruptions along the course of a nerve. Crusting and healing of the vesicular skin lesions indicate that acyclovir (Zovirax) is effective. C: Urticaria (swollen, raised areas) and pruritus (itching) are not symptoms of herpes zoster. D: The lesions of chicken pox are generalized, whereas herpes zoster lesions occur along the course of a nerve. Herpes zoster occurs when the chicken pox (varicella zoster) virus that has incorporated itself into nerve cells is reactivated years after the initial infection, but it is not chicken pox.
Six months after starting disulfiram for treatment of alcoholism, the client has serum laboratory tests completed (see exhibit). Place an X on each serum laboratory result that the nurse should report immediately to the HCP.
- A. Potassium
- B. Albumin
- C. AST
- D. ALT
- E. Total bilirubin
- F. Alkanine Phosphatase
- G. RBCs
Correct Answer: B,C,DE,F
Rationale: Abnormal liver function tests (low albumin, elevated AST, ALT, total bilirubin, ALP) should be reported due to disulfiram's potential liver effects. [Image-based question; X on abnormal LFTs.]
The major electrolytes in the extracellular fluid are:
- A. potassium and chloride.
- B. potassium and phosphate.
- C. sodium and chloride.
- D. sodium and phosphate.
Correct Answer: C
Rationale: Sodium and chloride are the major electrolytes in the extracellular fluid.
The client experiencing an acute attack of gouty arthritis is prescribed colchicine 1 mg IV now and then 0.5 mg q6h. Colchicine 0.5 mg/mL in a 2-mL ampule is available. How many milliliters should the nurse administer for the initial dose?
Correct Answer: 2
Rationale: Use a proportion formula; multiply the extremes (outside values) and then the means (inside values), and solve for X. 0.5 mg: 1 mL :: 1 mg: X mL; 0.5X = 1; 1 / 0.5 = 2; X = 2 mL. Colchicine (Colcrys) interferes with the function of WBCs in initiating and perpetuating the inflammatory response to monosodium urate crystals.