Nokea
The school nurse is conducting health screenings on schoolchildren. During the screening, she identifies a child with the behavioral characteristics of attention deficit disorder. Which of the following behaviors is consistent with this disorder?
- A. slow speech development
- B. overreaction to stimuli from the surroundings
- C. inability to carry on a conversation
- D. concrete thinking
Correct Answer: B
Rationale: The correct answer is 'overreaction to stimuli from the surroundings.' Children with attention deficit disorder often exhibit hypersensitivity to stimuli, leading to overreactions. Slow speech development is not a hallmark of attention deficit disorder; it is more associated with other learning disabilities. While children with this disorder may have difficulty focusing, they can usually carry on a conversation. Concrete thinking is not a common characteristic of attention deficit disorder, as individuals with this disorder may struggle with abstract thinking and impulsivity.
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A healthcare professional reviewing a client's health care record notes documentation that the client has Heberden nodes of the distal interphalangeal joints. Which disorder does the healthcare professional determine that the client has?
- A. Scoliosis
- B. Osteoarthritis
- C. Rotator cuff lesions
- D. Carpal tunnel syndrome
Correct Answer: B
Rationale: The correct answer is Osteoarthritis. Osteoarthritis is characterized by hard, nontender nodules of 2 to 3 mm or larger. These osteophytes (bony overgrowths) of the distal interphalangeal joints are called Heberden nodes. In this disorder, when these nodes occur on the proximal interphalangeal joints, they are called Bouchard nodes. Heberden nodes are not associated with scoliosis, rotator cuff lesions, or carpal tunnel syndrome. Therefore, choices A, C, and D are incorrect.
Which of the following client groups should the nurse recognize as the fastest-growing segment of the homeless population?
- A. single, adult men
- B. single mothers with 2 or 3 children
- C. runaway adolescents
- D. single, adult women
Correct Answer: B
Rationale: Single mothers with two or three children are indeed the fastest-growing segment of the homeless population. These families, where the majority of children are under the age of five, make up more than one-third of the homeless population in the United States. While single, adult men have traditionally been the largest group in the homeless population, single mothers with children have been increasing in numbers. Runaway adolescents, although a significant group of homeless children, do not represent the fastest-growing segment of the homeless population. Single, adult women are not specified as the fastest-growing segment.
A nurse assisting with data collection notes that the client's skin is very dry. The nurse documents this finding using which term?
- A. Xerosis
- B. Pruritus
- C. Seborrhea
- D. Actinic keratoses
Correct Answer: A
Rationale: Dry skin is also called xerosis. In this condition, the epidermis lacks moisture or sebum and is often marked by a pattern of fine lines, scaling, and itching. Xerosis is the correct term for very dry skin. Pruritus is the symptom of itching, an uncomfortable sensation that prompts the urge to scratch the skin, but it does not specifically refer to dry skin. Seborrhea is a skin condition characterized by overproduction of sebum, leading to excessive oiliness or dry scales, not necessarily indicating very dry skin. Actinic keratoses are sun-related skin lesions that are premalignant and not associated with dry skin.
When assessing a client with deep pitting edema, with the indentation remaining for a short time and visible leg swelling, how should a nurse document this finding?
- A. 1+ edema
- B. 2+ edema
- C. 3+ edema
- D. 4+ edema
Correct Answer: C
Rationale: The correct answer is 3+ edema. When assessing for edema, the nurse presses thumbs against the ankle malleolus or the tibia. If the skin retains an indentation, it indicates pitting edema. The grading scale for pitting edema includes: 1+ for mild pitting with slight indentation and no perceptible leg swelling, 2+ for moderate pitting where the indentation subsides rapidly, 3+ for deep pitting with an indentation remaining briefly and visible leg swelling, and 4+ for very deep pitting with a long-lasting indentation and significant leg swelling. Choices A, B, and D do not accurately represent the severity of the edema described in the scenario.
Which of the following actions should the LPN perform for a client with an active digoxin IV order? Select all that apply.
- A. plug the patient to the ECG Monitor
- B. Administer the medication over at least 5 minutes.
- C. Monitor respirations during administration.
- D. Monitor the client's pulse for 1 minute prior to administration.
Correct Answer: D
Rationale: The correct actions for the LPN to perform for a client with an active digoxin IV order are to monitor ECG rhythm throughout administration and monitor the client's pulse for 1 minute prior to administration. These actions are crucial as digoxin affects the heart's electrical activity, and it should not be administered if the client's pulse is less than 60 bpm. Monitoring respirations and blood pressure are not directly associated with digoxin administration. Administering IV medications is typically outside the LPN's scope of practice.