Nokea
The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
- A. Unequal leg length
- B. Limited adduction
- C. Diminished femoral pulses
- D. Symmetrical gluteal folds
Correct Answer: A
Rationale: In developmental dysplasia of the hip (DDH), one of the key findings is unequal leg length. This occurs due to the dislocation of the hip joint, where the ball is loose in the socket. Limited adduction, the inability to bring the hip and knee towards the midline of the body, is also a common finding in DDH. Diminished femoral pulses are not typically associated with DDH, as it primarily affects the skeletal structure rather than vascular supply. Symmetrical gluteal folds are normal in infants and do not indicate DDH, as asymmetry in gluteal folds can be a sign of hip dislocation.
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The nurse is caring for a 36-year-old patient with pancreatic cancer. Which nursing action is the highest priority?
- A. Offer psychological support for depression.
- B. Offer high-calorie, high-protein dietary choices.
- C. Administer prescribed opioids to relieve pain as needed.
- D. Teach about the need to avoid scratching any pruritic areas.
Correct Answer: C
Rationale: The correct answer is to administer prescribed opioids to relieve pain as needed. Pain management is the highest priority in this scenario as effective pain control is essential for the patient's overall well-being. Pain relief will not only improve the patient's comfort but also enhance their ability to eat, follow dietary recommendations, and be open to psychological support. Offering psychological support for depression (Choice A) is important but addressing pain takes precedence. While providing high-calorie, high-protein dietary choices (Choice B) is crucial, it is secondary to managing pain. Teaching about the need to avoid scratching pruritic areas (Choice D) is relevant but not the highest priority in this situation where pain management is critical for the patient's quality of life.
To palpate the liver during a head-to-toe physical assessment, the nurse should
- A. put pressure on the biopsy site using a sandbag
- B. elevate the head of the bed to facilitate breathing
- C. place the patient on the right side with the bed flat
- D. check the patient's post-biopsy coagulation studies
Correct Answer: C
Rationale: To palpate the liver effectively during a head-to-toe physical assessment, the patient should be positioned on the right side with the bed flat. This position helps to splint the biopsy site and allows for proper palpation of the liver. Elevating the head of the bed has no direct relevance to palpating the liver. Checking coagulation studies is done before the biopsy and is unrelated to palpation. Putting pressure on the biopsy site using a sandbag is not an appropriate way to facilitate liver palpation as it does not provide the necessary support and stabilization needed for the procedure.
To prepare a 56-year-old male patient with ascites for paracentesis, the nurse should?
- A. place the patient on NPO status.
- B. assist the patient to lie flat in bed.
- C. ask the patient to empty the bladder.
- D. position the patient on the right side.
Correct Answer: C
Rationale: To prepare a patient with ascites for paracentesis, the nurse should ask the patient to empty the bladder. This is important to decrease the risk of bladder perforation during the procedure. The patient should be positioned in Fowler's position to facilitate the procedure, not lie flat in bed, which can compromise breathing. Placing the patient on NPO status is unnecessary as sedation is not typically required for paracentesis. Positioning the patient on the right side is not a standard preparatory measure for paracentesis.
The nurse recognizes that teaching a 44-year-old woman following a laparoscopic cholecystectomy has been effective when the patient states which of the following?
- A. I can expect yellow-green drainage from the incision for a few days.
- B. I can remove the bandages on my incisions tomorrow and take a shower.
- C. I should plan to limit my activities and not return to work for 4 to 6 weeks.
- D. I will always need to maintain a low-fat diet since I no longer have a gallbladder.
Correct Answer: B
Rationale: The correct answer is, 'I can remove the bandages on my incisions tomorrow and take a shower.' After a laparoscopic cholecystectomy, patients have Band-Aids over the incisions and can typically remove the bandages the next day. Patients are usually discharged the same or next day and have minimal restrictions on their daily activities. Yellow-green drainage from the incision would be abnormal, requiring the patient to contact their healthcare provider. While a low-fat diet may be recommended initially after surgery, it is not a lifelong requirement, as the body can adjust to the absence of the gallbladder over time. Choice A is incorrect as abnormal drainage should be reported. Choice C is incorrect as most patients can resume normal activities within a few days to a week. Choice D is incorrect as maintaining a low-fat diet is not a lifelong necessity after a cholecystectomy.
A client is seen for testing to rule out Rocky Mountain Spotted Fever. Which of the following signs or symptoms is associated with this condition?
- A. Fever and rash
- B. Circumoral cyanosis
- C. Elevated glucose levels
- D. All of the above
Correct Answer: A
Rationale: The correct answer is 'Fever and rash.' Rocky Mountain Spotted Fever (RMSP) is caused by the R. rickettsii pathogen, which damages blood vessels. Patients with RMSP typically present with fever, edema, and a rash that initially appears on the hands and feet before spreading across the body. The disease manifests following a tick bite. Choice A is correct as fever and rash are key indicators of RMSP. Circumoral cyanosis (choice B) is not typically associated with RMSP; it refers to a bluish discoloration around the mouth and is more indicative of oxygen deprivation. Elevated glucose levels (choice C) are not specific signs of RMSP. Therefore, choice D, 'All of the above,' is incorrect since only choice A, 'Fever and rash,' is associated with Rocky Mountain Spotted Fever.