Nokea
The RN is planning care at a team meeting for a 2-month-old child in bilateral leg casts for congenital clubfoot. Which of these suggestions by the PN should be considered the priority nursing goal following cast application?
- A. Infant will experience minimal pain
- B. Muscle spasms will be relieved
- C. Mobility will be managed as tolerated
- D. Tissue perfusion will be maintained
Correct Answer: D
Rationale: Following cast application for congenital clubfoot in a 2-month-old child, the priority nursing goal should be to maintain tissue perfusion. This is crucial to prevent complications like compartment syndrome and ensure proper healing. While managing pain, relieving muscle spasms, and promoting mobility are important aspects of care, they are secondary to ensuring adequate tissue perfusion in this scenario.
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Which ethnic group has the highest risk for diabetes?
- A. African Americans
- B. Hispanic Americans
- C. Asian Americans
- D. Native Americans
Correct Answer: D
Rationale: Native Americans have the highest risk for diabetes compared to other ethnic groups. This is due to genetic predisposition, lifestyle factors, and limited access to healthcare. African Americans, Hispanic Americans, and Asian Americans also have an increased risk of developing diabetes, but statistically, Native Americans have the highest prevalence of the disease. Therefore, choices A, B, and C are incorrect.
The nurse is evaluating the growth and development of a toddler with AIDS. The nurse would anticipate finding that the child has
- A. Achieved developmental milestones at an erratic rate
- B. Delay in musculoskeletal development
- C. Displayed difficulty with speech development
- D. Delay in achievement of most developmental milestones
Correct Answer: D
Rationale: Children with AIDS often experience delays in achieving developmental milestones, affecting their overall growth and development. This delay can impact various areas of development, not limited to a specific aspect like musculoskeletal or speech development. While some children may achieve milestones at varying rates (choice A), the general trend is a delay in multiple milestones (choice D). Musculoskeletal development (choice B) and speech development (choice C) may be affected but are not as comprehensive as the delay in most developmental milestones.
Under the local government code, health services must be developed by the local governments. This means that local health agencies such as health centers/rural health centers must be under the:
- A. municipal government office
- B. barangay health councils
- C. district health office
- D. provincial health office
Correct Answer: A
Rationale: The correct answer is A: municipal government office. According to the local government code, local health agencies like health centers and rural health centers are managed by the municipal government office. This is because the municipal government is responsible for providing essential public services within their jurisdiction. Choice B, barangay health councils, is incorrect as they operate at a smaller administrative level than municipal government offices. Choice C, district health office, is not the correct level of government responsible for managing local health agencies. Choice D, provincial health office, is at a higher administrative level than the municipal government office and is not directly responsible for managing local health agencies.
The nurse is teaching a community group about risks of cardiovascular disease. Several clients ask the nurse to determine their risk. Which client should the nurse identify as having the greatest risk for cardiovascular disease?
- A. A male with a serum cholesterol level of 199 mg/dl.
- B. A female with a serum cholesterol level of 201 mg/dl.
- C. A male with a low-density lipoprotein (LDL) level of 200 mg/dl.
- D. A female with a low-density lipoprotein (LDL) level of 160 mg/dl.
Correct Answer: C
Rationale: The correct answer is C. A male with a high LDL level (200 mg/dl) has a significant risk for cardiovascular disease. High levels of LDL cholesterol are associated with an increased risk of atherosclerosis and heart disease. Choices A, B, and D have serum cholesterol levels that are slightly elevated but are not as specific or directly linked to cardiovascular risk as high LDL levels. Therefore, the client with the high LDL level is at the greatest risk for cardiovascular disease.
A client with peptic ulcer disease is receiving ranitidine (Zantac). The nurse should monitor the client for which of the following side effects?
- A. Hypertension
- B. Constipation
- C. Diarrhea
- D. Hypotension
Correct Answer: C
Rationale: The correct answer is C: Diarrhea. Ranitidine, which is used to treat peptic ulcer disease, can lead to gastrointestinal disturbances such as diarrhea. Choices A, B, and D are incorrect. Hypertension and hypotension are not common side effects of ranitidine. Constipation is also not a typical side effect associated with ranitidine use.