Nokea
The physician has made a diagnosis of 'shaken child' syndrome for a 13-month-old who was brought to the emergency room after a reported fall from his highchair. Which finding supports the diagnosis of 'shaken child' syndrome?
- A. Fracture of the clavicle
- B. Periorbital bruising
- C. Retinal hemorrhages
- D. Fracture of the humerus
Correct Answer: C
Rationale: Retinal hemorrhages are a hallmark of shaken baby syndrome due to the shearing forces from violent shaking causing bleeding in the retina.
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A community center is having a health fair. Which of the following main food courses should the nurse recommend as most healthful for a 20-year-old adult whose total cholesterol level is 300 mg/dL?
- A. fettuccine alfredo
- B. fried chicken
- C. grilled cheese sandwich with bacon
- D. natural peanut butter and banana sandwich on whole wheat bread
Correct Answer: D
Rationale: The peanut butter and banana sandwich on whole wheat bread is lower in saturated fats and healthier for managing high cholesterol.
If a group includes only members selected on a specific basis, such as women with a history of domestic or partner abuse, how is this type of group classified?
- A. Homogeneous
- B. Closed
- C. Heterogeneous
- D. Task
Correct Answer: A
Rationale: A group with members sharing a specific characteristic, like domestic abuse history, is homogeneous (A). Closed (B) refers to membership limits, heterogeneous (C) to diversity, and task (D) to purpose.
A client has experienced 48 hours of severe repeated bouts of vomiting. Which acid-base imbalance is of most concern?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: D
Rationale: Severe vomiting causes loss of gastric acid, leading to metabolic alkalosis (D). Respiratory imbalances (A, B) and metabolic acidosis (C) are less likely.
A client on a mechanical ventilator begins to fight the ventilator. Which medication will be ordered for the client?
- A. Sublimaze (fentanyl)
- B. Pavulon (pancuronium bromide)
- C. Versed (midazolam)
- D. Atarax (hydroxyzine)
Correct Answer: B
Rationale: Pavulon, a neuromuscular blocker, is used to paralyze respiratory muscles in clients fighting the ventilator, ensuring effective ventilation.
The nurse is aware that the best way to prevent post-operative wound infection in the surgical client is to:
- A. Administer a prescribed antibiotic
- B. Wash her hands for 2 minutes before care
- C. Wear a mask when providing care
- D. Ask the client to cover her mouth when she coughs
Correct Answer: B
Rationale: Hand washing is the most effective measure to prevent postoperative wound infections.