Nokea
The nurse has a 2-year-old boy sit in "tailor" position during palpation for the testes. What is the rationale for this position?
- A. It prevents cremasteric reflex.
- B. Undescended testes can be palpated.
- C. This tests the child for an inguinal hernia.
- D. The child does not yet have a need for privacy.
Correct Answer: A
Rationale: The "tailor" position, also known as the frog-leg position, is used during palpation for the testes in young boys because it helps prevent the cremasteric reflex. The cremasteric reflex is a normal reflex in which the testes are pulled upwards towards the inguinal canal when the inner thigh is stroked. By having the child sit in the tailor position, with the knees pulled up and legs rotated outwards, the reflex is less likely to be elicited, allowing for a more accurate examination of the testes.
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or a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?
- A. "Client verbalizes feelings of anxiety."
- B. "Client doesn't guess at prognosis."
- C. "Client uses any effective method to reduce tension."
- D. "Client stops seeking information."
Correct Answer: C
Rationale: The most appropriate expected outcome for a client experiencing anxiety related to a cancer diagnosis would be "Client uses any effective method to reduce tension." This outcome focuses on the client actively managing their anxiety by utilizing various strategies to decrease tension and promote feelings of calmness. It empowers the client to take control of their anxiety and seeks to foster a sense of well-being during a difficult time. The other options do not directly address the active management of anxiety as effectively as option C.
The nurse is caring for an adolescent who has just started dialysis. The child seems always angry, hostile, or depressed. To what are these behaviors most likely related?
- A. Neurologic manifestations that occur with dialysis
- B. Physiologic manifestations of renal disease
- C. Adolescents having few coping mechanisms
- D. Adolescents often resenting the control and enforced dependence imposed by dialysis
Correct Answer: D
Rationale: Adolescents often resent the control and enforced dependence imposed by dialysis. Adolescence is a challenging time marked by striving for independence and autonomy. When adolescents have to rely on medical interventions like dialysis that impose control and dependence, it can lead to feelings of anger, hostility, and depression. This is a normal psychological response to feeling restricted and not in control of their own lives. It is important for healthcare providers to recognize these emotions and provide support and coping strategies to help the adolescent adjust to the situation.
Which is instituted for the therapeutic management of minimal change nephrotic syndrome?
- A. Corticosteroids
- B. Antihypertensive agents
- C. Long-term diuretics
- D. Increased fluids to promote diuresis
Correct Answer: A
Rationale: Corticosteroids are the mainstay of therapy for minimal change nephrotic syndrome. Minimal change disease is the most common cause of nephrotic syndrome in children, and corticosteroids are highly effective in inducing remission in these patients. They work by reducing inflammation and decreasing the permeability of the glomerular filtration barrier in the kidneys, thereby reducing proteinuria. Antihypertensive agents are used to control blood pressure in patients with renal involvement, and long-term diuretics are not typically recommended in nephrotic syndrome due to the risk of worsening kidney function. Increased fluids to promote diuresis are also not indicated as the primary treatment for minimal change nephrotic syndrome.
Which is an important nursing consideration in the care of the newborn with PKU?
- A. Suggest ways to make formula more palatable.
- B. Teach proper administration of phenylalanine hydroxylase.
- C. Encourage the breastfeeding mother to adhere to a low-phenylalanine diet.
- D. Give reassurance that dietary restrictions are a temporary inconvenience.
Correct Answer: C
Rationale: Encouraging the breastfeeding mother to adhere to a low-phenylalanine diet is an important nursing consideration in the care of the newborn with PKU. Phenylketonuria (PKU) is an inborn error of metabolism in which the body cannot metabolize phenylalanine properly. If a newborn with PKU consumes formula or breast milk that contains high levels of phenylalanine, it can lead to severe intellectual disability and other health complications. By encouraging the breastfeeding mother to follow a low-phenylalanine diet, the newborn's exposure to phenylalanine can be minimized, helping to prevent the negative effects of PKU.
The serum alpha-fetoprotein (AFP) level is elevated with some malignant germ cell tumors (GCTs) especially endodermal sinus tumors; it can be used as a measure of treatment response and during follow-up after completion of chemotherapy. However, it is normally elevated during infancy. At which age does AFP physiologically fall to normal adult level?
- A. three month
- B. eight month
- C. one year
- D. three year
Correct Answer: C
Rationale: AFP levels typically normalize by around one year of age.