Nokea
Which of the following findings is most typical of a client with a fractured hip?
- A. Pain in the hip and affected leg
- B. Diminished sensation in the affected leg
- C. Absence of pedal and femoral pulses in the affected extremity
- D. Disalignment of the affected extremity
Correct Answer: A
Rationale: Pain in the hip and leg is the most typical symptom of a hip fracture. Diminished sensation, absent pulses, or disalignment may occur but are less common.
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A newly diagnosed HIV patient is in your care. The patient has a positive PPD result of 5 mm induration and a normal CXR.
Which of the following represents preferred treatment of this patient?
- A. INH and pyridoxine
- B. IHN and Rifampin
- C. Rifampin and Streptomycin
- D. No pharmacotherapeutic regimen necessary.
Correct Answer: A
Rationale: INH with pyridoxine is the standard treatment for latent TB in HIV patients with a positive PPD.
Homonymous hemianopsia:
Homonymous hemianopsia:
- A. Half of the visual field of the affected eye is lost.
- B. The pupil in the affected eye is always dilated.
- C. Lost of vision on the affected eye.
- D. The pupil in the affected eye is not constricting.
Correct Answer: A
Rationale: Homonymous hemianopsia involves loss of half the visual field in both eyes, same side.
The nurse is caring for a 10-year-old child who has classic hemophilia. He is admitted with a swollen right knee that is very painful. The nurse should plan to include which of the following as a priority in the care of this child upon admission?
- A. Range-of-motion exercises to maintain joint mobility
- B. Ambulation at least three times a day to prevent immobility complications
- C. A bed cradle to reduce pain
- D. Offer 250 mL of fluid every hour to prevent hemarthrosis
Correct Answer: C
Rationale: A bed cradle keeps bedding off the painful, swollen knee (hemarthrosis), reducing discomfort, a priority in acute hemophilia management.
A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding the most significant?
- A. Decreased level of consciousness (LOC)
- B. Elevated blood pressure
- C. Increased urine output
- D. Decreased heart rate
Correct Answer: C
Rationale: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.
A 5-month-old infant is admitted to the ER with a temperature of 103.6° and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Correct Answer: B
Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure, a critical sign in bacterial meningitis.