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Which blood gas analyses are most indicative of respiratory acidosis?
- A. pH = 7.22, PCO2 = 55 mmHg, HCO3 = 30 mEq/L.
- B. pH = 7.28, PCO2 = 45 mmHg, HCO3 = 15 mEq/L.
- C. pH = 7.34, PCO2 = 35 mmHg, HCO3 = 25 mEq/L.
- D. pH = 7.40, PCO2 = 25 mmHg, HCO3 = 30 mEq/L.
Correct Answer: A
Rationale: Respiratory acidosis is indicated by a low pH and elevated PCO2, as seen in option A.
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Vitamin A supplementation may be recommended for the young child who has which disease?
- A. Mumps
- B. Rubella
- C. Measles (rubeola)
- D. Erythema infectiosum
Correct Answer: C
Rationale: Vitamin A supplementation may be recommended for children with measles (rubeola) due to the disease's association with vitamin A deficiency. Measles can lead to reduced levels of vitamin A in the body, which can result in increased severity of symptoms, complications, and even death. Supplementing with vitamin A during and after a measles infection helps reduce the risk of complications and mortality, particularly in young children under the age of 5 in areas where vitamin A deficiency is common. Therefore, providing vitamin A supplementation to children with measles is an important intervention to support their recovery and improve outcomes.
An 8-day-old is admitted with vomiting and dehydration. His HR is 170, RR is 44, BP is 85/52, and T is 99°F. The parents ask if these vital signs are normal. Which is the best response?
- A. The BP is elevated.
- B. The temperature is elevated.
- C. The heart rate is elevated; normal for a neonate is 90-160 bpm.
- D. The respiratory rate is elevated.
Correct Answer: C
Rationale: A neonatal heart rate of 170 is above the normal range (90-160 bpm), which is concerning for dehydration.
The nurse knows that Parkinson's disease a progressive neurologic disorder is characterized by:
- A. Bradykinesia
- B. Tremor
- C. Muscle rigidity
- D. All of the above
Correct Answer: D
Rationale: Parkinson's disease is a progressive neurologic disorder that is characterized by a triad of symptoms known as the classic Parkinsonian triad. These symptoms include bradykinesia (slowness of movement), tremor (involuntary shaking), and muscle rigidity (stiffness of the muscles). Therefore, all of the given choices are correct in describing the characteristics of Parkinson's disease.
A client has a serum calcium level of 7.2mg/dl. During the physical examination, the nurse expects to assess:
- A. Trousseau's sign
- B. Hegar's sign
- C. Homan's sign
- D. Goodell's sign
Correct Answer: A
Rationale: A client with a low serum calcium level (hypocalcemia) is at risk for exhibiting Trousseau's sign. Trousseau's sign is a clinical manifestation of hypocalcemia characterized by carpal spasm induced by inflating a blood pressure cuff on the arm above the systolic pressure for a few minutes. This spasm occurs due to the increased neuromuscular irritability caused by low calcium levels. Therefore, a nurse assessing a client with a serum calcium level of 7.2mg/dl should expect to assess Trousseau's sign.
A neonate, who was delivered by Cesarean section for a breech presentation, is being examined in the neonatal nursery. For which of the following complications should the nurse carefully assess the baby?
- A. Developmental dysplasia of the hips (DDH)
- B. Legg-Calve-Perthes (LCP)
- C. Duchenne muscular dystrophy (DMD)
- D. Slipped capital femoral epiphysis (SCFE)
Correct Answer: A
Rationale: A neonate delivered by Cesarean section for a breech presentation is at higher risk for developmental dysplasia of the hips (DDH). Breech presentation, especially frank breech, increases the chance of hip instability and DDH due to the positioning of the legs in utero. DDH is a condition where the ball and socket joint of the hip does not properly form, leading to potential dislocation of the hip joint. It is important for the nurse to carefully assess the neonate for signs of hip dysplasia, such as limited hip abduction or asymmetry in the thigh folds, to facilitate early detection and intervention for optimal outcomes. Legg-Calve-Perthes (LCP), Duchenne muscular dystrophy (DMD), and slipped capital femoral epiphysis (SCFE) are not specifically related to breech delivery, and therefore, are less likely to be