Nokea
Which nursing assessment finding indicates the presence of an inguinal hernia on a child?
- A. Reports of difficulty defecating
- B. Reports of a dribbling urinary stream
- C. Absence of the testes within the scrotum
- D. Painless groin swelling noticed when the child cries
Correct Answer: D
Rationale: Inguinal hernia is a common defect that may appear as a painless inguinal (groin) swelling when the child cries or strains. Option 1 is a symptom indicating a partial obstruction of the herniated loop of intestine. Option 2 describes a sign of phimosis, a narrowing or stenosis of the preputial opening of the foreskin. Option 3 describes cryptorchidism.
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The pediatric nurse specialist teaches nursing students about mumps. Which clinical manifestation will the specialist identify as the most common complication of this disease?
- A. Pain
- B. Nuchal rigidity
- C. Impaired hearing
- D. A red swollen testicle
Correct Answer: B
Rationale: The most common complication of mumps is aseptic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. Muscular pain, parotid pain, or testicular pain may occur, but pain does not indicate a sign of a common complication. Although mumps is one of the leading causes of unilateral nerve deafness, it does not occur frequently. A red swollen testicle may be indicative of orchitis. Although this complication appears to cause most concern among parents, it is not the most common complication.
On assessment of a newborn being admitted to the nursery, the nurse palpates the anterior fontanel and notes that it feels soft. The nurse determines that this finding indicates which condition?
- A. Dehydration
- B. A normal finding
- C. Increased intracranial pressure
- D. Decreased intracranial pressure
Correct Answer: B
Rationale: The anterior fontanel is normally 2 to 3 cm in width, 3 to 4 cm in length, and diamond-like in shape. It can be described as soft, which is normal, or full and bulging, which could indicate increased intracranial pressure. Conversely a depressed fontanel could mean that the infant is dehydrated.
The nurse is analyzing an electrocardiogram (ECG) rhythm strip on an assigned client. What should the nurse record as the client's PR interval?
- A. 0.12 second
- B. 0.20 second
- C. 0.24 second
- D. 0.40 second
Correct Answer: A
Rationale: Standard ECG graph paper measurements are 0.04 second for each small box on the horizontal axis (measuring time) and 1 mm (measuring voltage) for each small box on the vertical axis.
The nurse is creating a plan of care for a client diagnosed with a dissecting abdominal aortic aneurysm. Which interventions should be included in the plan of care? Select all that apply.
- A. Assess peripheral circulation.
- B. Monitor for abdominal distention.
- C. Educate the client that abdominal pain is to be expected.
- D. Assess the client for observable ecchymoses on the lower back.
- E. Perform deep palpation of the abdomen to assess the size of the aneurysm.
Correct Answer: A,B,D
Rationale: If the client has an abdominal aortic aneurysm, the nurse is concerned about rupture and monitors the client closely. The nurse should assess peripheral circulation and monitor for abdominal distention. The nurse also looks for ecchymoses on the lower back to determine if the aneurysm is leaking. The nurse tells the client to report abdominal pain, or back pain, which may radiate to the groin, buttocks, or legs because this is a sign of rupture. The nurse also avoids deep palpation in the client in whom a dissecting abdominal aortic aneurysm is known or suspected.
The nurse who practices culturally sensitive nursing care incorporates which concepts into client care? Select all that apply.
- A. The expression of pain is affected by learned behaviors.
- B. Physiologically, all individuals experience pain in a similar manner.
- C. Ethnic culture has an effect on the physiological response to pain medications.
- D. Clients should be assessed for pain regardless of a lack of overt symptomatology.
- E. The use of a standardized pain assessment tool ensures unbiased pain assessment.
Correct Answer: A,C,D
Rationale: Pain and its expression are often affected by an individual's ethnic culture in ways that include learned means of pain expression, the physiological response to pain medications, and attitudes regarding acceptable ways of dealing with pain. Physiologically not all individuals, even those of the same ethnic culture, will respond to pain in a similar manner, and so a standardized pain assessment tool is not effective in measuring pain in all clients.