Nokea
The nurse is assessing a 4 year-old for possible developmental dysplasia of the right hip. Which finding would the nurse expect?
- A. Pelvic tip downward
- B. Right leg lengthening
- C. Ortolani sign
- D. Characteristic limp
Correct Answer: D
Rationale: Characteristic limp. Developmental dysplasia produces a characteristic limp in children who are walking, indicating hip joint instability.
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Laboratory Reference Ranges
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
The student nurse completes a clinical rotation in the emergency department. The instructor knows the student is able to prioritize care appropriately when the student visits which client first?
- A. 9 year-old crying with pain and swelling of the left ankle after a popping sound while playing soccer
- B. 29-year-old with neck swelling and increased pain 2 days after thyroidectomy
- C. 43-year-old with blood glucose of 423 mg/dL (23.5 mmol/L), dehydration, and trace ketones in urine
- D. 72-year-old who is incontinent with acute altered mental status and is yelling at staff
Correct Answer: B
Rationale: Neck swelling and pain post-thyroidectomy suggest possible hematoma or airway compromise, a life-threatening emergency requiring immediate assessment. Other conditions, while serious, are less immediately critical.
The nurse is providing home care for an immobile client who has a stage IV decubitus ulcer that is not healing. Assuming that all of the following are available, which person would be most appropriate to consult regarding care of the wound?
- A. Physician
- B. Physical therapist
- C. IV therapist
- D. Enterostomal therapist
Correct Answer: D
Rationale: An enterostomal therapist specializes in wound and ostomy care, making them the most appropriate consultant for managing a non-healing stage IV decubitus ulcer. Physicians oversee care, physical therapists focus on mobility, and IV therapists manage infusions.
Which of the following instructions should be given to a client regarding testicular self-exam?
- A. The testicular exam should be done bimonthly.
- B. The testicular exam should be done while in the shower or tub.
- C. A small pen light should be used to transilluminate the scrotal sac.
- D. The testicular exam should be done yearly.
Correct Answer: B
Rationale: Testicular self-examination (TSE) is recommended monthly, not bimonthly or yearly, and is best performed during or after a warm shower or bath when the scrotum is relaxed, making it easier to detect abnormalities. Transillumination is a medical procedure, not part of TSE.
The nurse understands that during the 'tension building' phase of a violent relationship, when the batterer makes unreasonable demands, the battered victim may experience feelings of
- A. Anger
- B. Helplessness
- C. Calm
- D. Explosiveness
Correct Answer: B
Rationale: Helplessness. Victims feel depressed and helpless despite efforts to please the batterer.
The practical nurse is collaborating with the registered nurse to admit a client who will receive general anesthesia in the same-day surgery unit. The client has never had surgery before. Which question is most critical for the nurse to ask the client during preoperative assessment and health history taking?
- A. Has any family member ever had a bad reaction to general anesthesia?
- B. Have you ever experienced low back pain?
- C. Have you ever had an anaphylactic reaction to a bee sting?
- D. Have you ever received opioid pain medications?
Correct Answer: A
Rationale: A family history of adverse reactions to anesthesia (e.g., malignant hyperthermia) is critical, as it's a potentially fatal genetic condition. Other questions are less urgent for anesthesia safety.