Nokea
Which of the following has the highest proportion of etiology of congenital malformations?
- A. Maternal infections
- B. Maternal illness
- C. Environmental agents
- D. Monogenic inheritance
Correct Answer: D
Rationale: Monogenic inheritance accounts for the highest proportion of congenital malformations.
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The ECG in left ventricular hypertrophy and shows a superior QRS axis (between -90' and 0')
- A. tricuspid atresia
- B. Ebstein anomaly
- C. pulmonary atresia
- D. tetralogy of Fallot
Correct Answer: D
Rationale: Left ventricular hypertrophy with a superior QRS axis is characteristic of tetralogy of Fallot.
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?
- A. Inappropriate laughter
- B. Increasing anxiety
- C. Weakened cough effort
- D. Asymmetrical weakness
Correct Answer: C
Rationale: A weakened cough effort can lead to respiratory complications, which are life-threatening in ALS patients.
The nurse reviews the laboratory results of a client during an annual physical examination and identifies a positive guaiac test of stool. Which additional serum laboratory test result should the nurse review?
- A. Glucose
- B. Platelet count
- C. White blood cell count
- D. Amylase
Correct Answer: B
Rationale: A positive guaiac test indicates gastrointestinal bleeding. A platelet count is essential to assess for thrombocytopenia, which could contribute to bleeding.
Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock?
- A. Thirst
- B. Irritability
- C. Apprehension
- D. Confusion and somnolence
Correct Answer: D
Rationale: Confusion and somnolence are beginning signs of decompensated shock. Thirst, irritability, and apprehension are signs of compensated shock.
A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. The client is intubated and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain?
- A. Breath sounds over bilateral lung fields.
- B. Carotid pulsation during compressions
- C. Deep tendon reflexes
- D. Core body temperature
Correct Answer: A
Rationale: Assessing breath sounds ensures that the endotracheal tube is properly placed and that ventilation is effective, which is critical in a cardiac arrest situation.