Nokea
What might you conclude if you notice a wide perineum and unequal gluteal and thigh folds when assessing a newborn?
- A. Osteogenesis imperfecta
- B. Torticollis
- C. Scoliosis
- D. Hip dysplasia
Correct Answer: D
Rationale: When assessing a newborn and noticing a wide perineum and unequal gluteal and thigh folds, it may signal the possibility of developmental dysplasia of the hip (DDH), also known as hip dysplasia. DDH is a condition where the hip joint does not properly form in newborns, leading to instability and potential dislocation. The wide perineum and unequal gluteal and thigh folds are physical signs that can be indicative of hip dysplasia. It is essential to diagnose and treat hip dysplasia early to prevent long-term complications like difficulty walking and osteoarthritis. Regular screening of newborns for hip dysplasia risk factors and physical exam findings is crucial for early detection and intervention.
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a definitive diagnosis of sickle cell disease is based on which diagnostic result
- A. complete blood count (CBC )
- B. bone marrow aspiration
- C. blood chemistry test
- D. hemoglobin electrophoresis 128
Correct Answer: D
Rationale: A definitive diagnosis of sickle cell disease is based on hemoglobin electrophoresis. This test separates the different types of hemoglobin based on their electrical charge, allowing for the detection of abnormal hemoglobin variants such as hemoglobin S, which is characteristic of sickle cell disease. A complete blood count (CBC) can show various abnormalities seen in sickle cell disease, but it is not specific for confirming the diagnosis. Bone marrow aspiration is not routinely used for diagnosing sickle cell disease. Blood chemistry tests may reveal some complications associated with sickle cell disease but do not confirm the condition itself. Hemoglobin electrophoresis is the gold standard for diagnosing sickle cell disease by identifying the specific hemoglobin variant characteristic of the disorder.
Lily , age 5, with an intelligence quotient of 65 is admitted to the hospital for evaluation. When planning care, the nurse should keep in mind that this child is:
- A. Within the lower range of normal intelligence
- B. Mildly retarded but educable
- C. Moderately retarded but trainable
- D. Completely dependent on others for care
Correct Answer: C
Rationale: Lily, with an intelligence quotient of 65, falls into the category of moderate intellectual disability, which typically ranges from IQ 35-49 to 50-69. Children with moderate intellectual disability have limitations in intellectual functioning that result in difficulties with adaptive behaviors, learning, and social skills. They can benefit from training, therapies, and educational interventions to improve their functional abilities and quality of life. While they may require support and supervision in various aspects of daily living, they are not completely dependent on others for care like individuals with severe or profound intellectual disability. Therefore, the nurse should consider Lily as moderately retarded but trainable when planning care for her in the hospital.
You would not find which of the following assessments in a patient with severe anemia?
- A. Pallor
- B. Fatigue
- C. Cold sensitivity
- D. Dyspnea only on exertion
Correct Answer: C
Rationale: Severe anemia is associated with a reduced number of red blood cells, leading to decreased oxygen delivery to the body's tissues. Therefore, symptoms commonly seen in patients with severe anemia include pallor (pale skin), fatigue (due to decreased energy levels), and dyspnea (shortness of breath) especially on exertion (due to the heart working harder to compensate for the reduced oxygen-carrying capacity of the blood). Cold sensitivity is not a typical symptom of anemia and is not directly related to the reduced oxygen-carrying capacity of the blood.
A 72-year-old chemist has left lower lobe pneumonia. His nurse checks his oxygen saturation and the result is 86%. Which of the ff. actions by the nurse is best?
- A. Call the physician for an order for oxygen.
- B. No action necessary; this is a normal SaO
Correct Answer: A
Rationale: An oxygen saturation (SaO2) level of 86% is significantly below the normal range of 95-100%. This indicates hypoxemia, which means the body is not getting enough oxygen. In a patient with pneumonia, low oxygen saturation can lead to further respiratory compromise and potential organ damage. Therefore, it is essential for the nurse to notify the physician promptly to obtain an order for supplemental oxygen to correct the hypoxemia and improve the patient's oxygen saturation levels. Delay in addressing low oxygen levels can have serious consequences for the patient's health and recovery.
Which of the following statements would be the nurse's response to a famiiy member asking questions about a client's transient ischemic attack (TIA)?
- A. "I think you should ask the doctor. Would you like me to cail him for you?"
- B. " The blood supply to the brain has decreased causing permanent brain damage."
- C. "It Is a temporary interruption in the blood flow to the brain."
- D. "TIA means a transient ischemic attack."
Correct Answer: C
Rationale: The correct response would be: "It is a temporary interruption in the blood flow to the brain." This response provides a clear and accurate explanation of a transient ischemic attack (TIA), which is commonly known as a "mini-stroke." A TIA is indeed a temporary episode where there is a brief interruption in the blood flow to the brain, leading to symptoms similar to those of a stroke, but without lasting damage. This response would give the family member a better understanding of what a TIA is and help alleviate concerns about permanent brain damage.