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Which of the ff should qualify as an abnormal result in a Romberg test?
- A. Hypotension
- B. Swaying, losing balance, or arm drifting
- C. Sneezing and wheezing
- D. Excessive cerumen in the outer ear
Correct Answer: B
Rationale: During a Romberg test, the individual is asked to stand with feet together, arms at sides, and eyes closed. The tester then observes for swaying, losing balance, or arm drifting, which are signs of a positive Romberg test, indicating a potential issue with proprioception or vestibular function. Hypotension (choice A) refers to low blood pressure and is not directly assessed during a Romberg test. Sneezing and wheezing (choice C) are unrelated symptoms. Excessive cerumen in the outer ear (choice D) does not affect the results of a Romberg test focused on balance and proprioception.
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When palpating the brachial, radial, and femoral pulses of a neonate, the nurse notes a difference in pulse amplitude between the femoral and radial pulses bilaterally. This difference suggests:
- A. Patent ductus arteriosus
- B. Coarctation of the aorta
- C. Diminished cardiac output
- D. Left to right shunting in the heart. 104 Practice Exam I
Correct Answer: B
Rationale: Coarctation of the aorta is a congenital heart defect in which there is a narrowing of the aorta leading to differential pulses in the upper and lower extremities. In neonates, this can manifest as weaker femoral pulses compared to radial pulses due to decreased blood flow to the lower body. This difference in pulse amplitude between the femoral and radial pulses bilaterally is a classic finding in coarctation of the aorta, making it the most likely cause in this scenario. Other conditions like patent ductus arteriosus, diminished cardiac output, or left to right shunting in the heart may not specifically present with this particular pulse amplitude difference.
During a routine examination of a 10-mo-old male infant, you find a white pupillary reflex of the right eye; the eye movements are normal. You suspect retinoblastoma. Of the following, the BEST confirmatory diagnostic evaluation of this infant is
- A. indirect ophthalmoscopy with slit-lamp examination
- B. examination under general anesthesia by an experienced ophthalmologist
- C. orbital ultrasonography
- D. brain MRI
Correct Answer: B
Rationale: Examination under anesthesia by an experienced ophthalmologist is the gold standard for diagnosing retinoblastoma.
As the nurse collects data on a patient, which of the following is a symptom that may be found that the patient with anaphylaxis may be experiencing?
- A. Dermatitis
- B. Sinusitis
- C. Delirium
- D. Wheezing
Correct Answer: D
Rationale: Wheezing is a common symptom of anaphylaxis, along with other signs such as difficulty breathing, chest tightness, coughing, and throat swelling. Wheezing is caused by the constriction of the airways due to the body's extreme immune response to the allergen, leading to difficulty in breathing and wheezing sounds during respiration. It is important for healthcare professionals to recognize wheezing as a symptom of anaphylaxis and respond promptly with appropriate interventions, such as administering epinephrine and providing respiratory support.
The nurse has determined the rate of both the child's radial pulse and heart. What is the normal finding when comparing the two rates?
- A. Are the same
- B. Differ, with heart rate faster
- C. Differ, with radial pulse faster
- D. Differ, depending on quality and intensity
Correct Answer: A
Rationale: In a normal healthy individual, the rate of the radial pulse (peripheral pulse) and the heart rate (apical pulse) should be the same. This is because each heartbeat should result in a corresponding pulse felt at the radial artery in the wrist. The pulse is generated by the heart's contraction and the subsequent ejection of blood into the arteries, causing a wave of pressure that can be felt as the pulse. Therefore, in a healthy individual, the radial pulse rate should match the heart rate. If there is a significant difference between the two rates, it may indicate a cardiovascular abnormality or other underlying health condition that warrants further investigation.
A newly diagnosed patient asks what asthma is. Which of the ff. explanations by the nurse is correct?
- A. "Your airways are inflamed and spastic."
- B. ""You have fluid in your lungs that is causing shortness of breath."
- C. "Your airways are stretched and non-functional."
- D. "You have a low-grade infection that keeps your bronchial tree irritated."
Correct Answer: A
Rationale: Option A, "Your airways are inflamed and spastic," is the correct explanation of asthma. Asthma is a chronic respiratory condition characterized by inflammation and narrowing of the airways, which causes difficulty in breathing, coughing, and wheezing. The inflammation leads to the airways becoming extremely sensitive to various triggers, such as allergens, irritants, or exercise, resulting in spasms that further constrict the air passages. This constriction makes it challenging for air to move in and out of the lungs efficiently, leading to symptoms such as shortness of breath. It is essential for the patient to understand that asthma is primarily an inflammatory condition rather than a structural or infectious problem.