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The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?
- A. Collect the blood sample
- B. Assess radial pulse volume
- C. Apply pressure to the site
- D. Select another finger
Correct Answer: A
Rationale: The reddened and engorged appearance is due to increased blood flow, and the sample can still be collected.
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List FOUR other cardiac manifestations for Marfan’s syndrome, aside from aortopathy.
- A. Mitral valve prolapse/regurgitation
- B. Calcification of the mitral valve <40 years
- C. Dilation of pulmonary artery
- D. Dilation or dissection of ascending/descending aorta (<50 years old)
Correct Answer: A
Rationale: Marfan's syndrome may involve multiple cardiac complications including mitral valve prolapse and other structural heart abnormalities.
A 2-year-old child should be able to:
- A. Name three colours correctly
- B. Use plurals
- C. Build a tower of five blocks
- D. Kick a ball on request
Correct Answer: C
Rationale: A 2-year-old can typically build a tower of five blocks. Naming colors and using plurals are more advanced skills, and kicking a ball is variable.
Which should the nurse consider when preparing a school-age child and the family for heart surgery?
- A. Unfamiliar equipment should not be shown.
- B. Let the child hear the sounds of an ECG monitor.
- C. Avoid mentioning postoperative discomfort and interventions.
- D. Explain that an endotracheal tube will not be needed if the surgery goes well.
Correct Answer: B
Rationale: The child and family should be exposed to the sights and sounds of the intensive care unit (ICU). All positive, nonfrightening aspects of the environment are emphasized. The child should be shown unfamiliar equipment and its use demonstrated on a doll. Carefully prepare the child for the postoperative experience, including intravenous (IV) lines, incision, and endotracheal tube.
Nystagmus can be a presenting sign in:
- A. Partial albinism
- B. Retinopathy of prematurity
- C. Acute vestibulitis
- D. Medulloblastoma
Correct Answer: D
Rationale: Medulloblastoma, a type of brain tumor, can present with nystagmus due to its impact on the cerebellum and brainstem.
What are FOUR possible causes of left axis deviation in a newborn with features of Trisomy 21?
- A. AVSD
- B. Tricuspid atresia
- C. Pulmonary atresia with intact ventricular septum
- D. Mechanical shift
Correct Answer: A
Rationale: AVSD is a common congenital heart defect associated with Trisomy 21 and can lead to left axis deviation seen on ECG.