Nokea
What characteristic manifestation does the nurse caring for a child with Duchenne's muscular dystrophy document?
- A. Ambulates by holding onto furniture.
- B. Exhibits atrophy of the calf muscles.
- C. Falls frequently and is clumsy.
- D. Has delayed fine-motor development.
Correct Answer: C
Rationale: Frequent falling and clumsiness are hallmark signs of Duchenne's muscular dystrophy due to muscle weakness.
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The nurse performing a neurovascular check on a limb in traction would report and document which finding(s) as indicative of altered circulation?
- A. Pulse is equal to uncasted limb.
- B. Patient is aware of touch and warm and cold application.
- C. Limb is cool to the touch.
- D. Capillary refill is 5 seconds.
- E. Distal limb can flex and extend.
Correct Answer: C,D
Rationale: Cool limbs and capillary refill over 3 seconds indicate altered circulation, requiring immediate reporting.
Which intervention would be helpful in relieving morning discomfort associated with juvenile rheumatoid arthritis?
- A. Wearing splints at night to prevent extension contractures
- B. Applying moist heat packs upon awakening
- C. Taking a warm tub bath the evening before
- D. Sleeping with two pillows under the head
Correct Answer: B
Rationale: Moist heat packs upon awakening reduce morning stiffness associated with juvenile rheumatoid arthritis.
How does the pediatric skeletal system differ from that of the adult?
- A. Lower mineral content
- B. More ossification
- C. Open epiphyses
- D. Less porosity
- E. Greater strength
Correct Answer: A,C,E
Rationale: The pediatric skeletal system has lower mineral content, open epiphyses, and greater strength, with greater porosity, not less.
Which observation is most likely to cause the nurse to consider the possibility of child abuse when a mother says that her young child fell down the basement stairs?
- A. Red, green, and yellow bruises on his body.
- B. Bruises are dispersed on his head, arms, and legs.
- C. A broken arm last year, and the child being described as accident-prone.
- D. The mother is very anxious for her son to get medical attention.
Correct Answer: A
Rationale: Multiple bruise colors indicate injuries at different healing stages, suggesting possible abuse rather than a single incident.
Which assessment performed by a nursing student performing a neurovascular check alerts the instructor that further education is necessary?
- A. Pulses
- B. Capillary refill
- C. Movement
- D. Pupils
Correct Answer: D
Rationale: Pupil assessment is part of a neurological check, not a neurovascular check, which includes pulses, capillary refill, and movement.