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When assessing a female adolescent for scoliosis, what should the nurse ask the client to do?
- A. Bend forward at the waist with arms hanging freely.
- B. Lie flat on the floor and extend her legs straight from the trunk.
- C. Sit in a chair while lifting her feet and legs to a right angle with the trunk.
- D. Stand against a wall while pressing the length of her back against the wall.
Correct Answer: A
Rationale: When assessing a female adolescent for scoliosis, the nurse should ask the client to bend forward at the waist with arms hanging freely. This Adams forward bend test allows the nurse to evaluate the spine for any asymmetry, curvature, or rib hump that may indicate scoliosis. By observing the alignment of the spine while the client is in a forward bent position, the nurse can gather important information to determine if further evaluation or referral to a healthcare provider is necessary.
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What is the earliest age at which a satisfactory radial pulse can be taken in children?
- A. 1 year
- B. 2 years
- C. 3 years
- D. 6 years
Correct Answer: A
Rationale: A satisfactory radial pulse can be taken in children as young as 1 year old. The radial pulse is commonly checked in the wrist and is a valuable indicator of cardiac function. Children as young as 1 year old can have a palpable radial pulse, allowing healthcare providers to assess their heart rate and rhythm. It is important to be gentle when palpating a pulse in young children to avoid causing discomfort or distress.
You are discussing failure to thrive (FTT) with medical students. You mention that FTT is most often used to describe malnutrition related to environmental or psychosocial causes. An important statement that should be included in your discussion is
- A. FTT is often diagnosed by weight that falls below the 25th percentile for age
- B. a weight crossing one major percentile lines on the growth height should be evaluated for FTT chart over time is considered abnormal
- C. a weight of less than 60 % of the median weight for the height of the child
- D. small subset of the population naturally falls below the 3rd percentile but usually have normal weight for height
Correct Answer: B
Rationale: Crossing percentile lines on a growth chart indicates a significant deviation from the child's previous growth trajectory, which is a key indicator of potential FTT.
For a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?
- A. "Client verbalizes feelings of anxiety."
- B. "Client doesn't guess at prognosis."
- C. "Client uses any effective method to reduce tension."
- D. "Client stops seeking information."
Correct Answer: C
Rationale: The expected outcome that would be appropriate for a client with newly diagnosed cancer experiencing anxiety related to the threat of death would be "Client uses any effective method to reduce tension." This outcome focuses on the client actively engaging in coping strategies to reduce their anxiety. It is important for the client to actively participate in managing their anxiety by utilizing various methods to promote relaxation and reduce tension. It is a more proactive and empowering goal compared to simply verbalizing feelings of anxiety or stopping seeking information. By actively using effective methods to reduce tension, the client is taking steps to improve their emotional well-being and cope with the anxiety related to the cancer diagnosis.
The nurse is interviewing a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?
- A. Duodenal ulcer
- B. Weight gain
- C. Hemorrhoids
- D. Polyps
Correct Answer: D
Rationale: The presence of polyps in the colon is a significant risk factor for developing colorectal cancer. Polyps are abnormal growths in the inner lining of the colon or rectum that can potentially become cancerous over time if left untreated. Therefore, if a client has a history of polyps, the nurse may suspect the possibility of colorectal cancer and should closely monitor the client for any signs or symptoms. While the other conditions listed may sometimes be associated with colorectal cancer, having a history of polyps is the most concerning in this context.
Which laboratory results (besides hematuria) are most consistent with hemolytic uremic syndrome (HUS)?
- A. Massive proteinuria, elevated BUN and creatinine.
- B. Mild proteinuria, decreased BUN and creatinine.
- C. Mild proteinuria, increased BUN and creatinine.
- D. Massive proteinuria, decreased BUN and creatinine.
Correct Answer: C
Rationale: HUS typically presents with mild proteinuria along with increased BUN and creatinine, reflecting impaired renal function.