Nokea
Which of the following malignant tumors is least likely to occur in adults in comparison with children?
- A. acute Lymphoblastic Leukemia (ALL)
- B. osteosarcoma
- C. medulloblastoma
- D. retinoblastoma
Correct Answer: D
Rationale: Retinoblastoma predominantly occurs in children under 5 years of age, making it the least likely to occur in adults.
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When performing a physical examination on an infant, the nurse in charge notes abnormally low- set ears. This finding is associated with:
- A. Otogenous tetanus
- B. Tracheoesophageal fistula
- C. Congenital heart defects
- D. Renal anomalies
Correct Answer: C
Rationale: Abnormally low-set ears are often associated with certain congenital anomalies, including congenital heart defects. When a nurse notes this finding during a physical examination of an infant, it is important to consider the possibility of congenital anomalies and further assessment for associated conditions. Low-set ears alone are not diagnostic of a specific congenital heart defect, but they can serve as a clue to support the need for further evaluation to rule out any underlying cardiac issues. Other congenital anomalies that may be associated with low-set ears include renal anomalies, which makes option D a distractor in this case.
A 15-month-old toddler was able to do all the following EXCEPT
- A. walks alone
- B. makes tower of 3 cubes
- C. inserts raisin in a bottle
- D. responds to his/her name
Correct Answer: D
Rationale: Responding to name usually occurs earlier, around 6-9 months.
Clients with myastherda gravis, Guillain - Barre Syndrome or amyothrophic sclerosis experience:
- A. Progressive deterioration until death
- B. Deficiencies of essential neurotransmitter
- C. Increased risk of respiratory complications
- D. Involuntary twitching of small muscle group
Correct Answer: C
Rationale: Clients with myasthenia gravis, Guillain-Barre Syndrome, or amyotrophic lateral sclerosis (ALS) are all affected by various neuromuscular conditions that can lead to respiratory complications. These conditions can cause weakness in the muscles involved in breathing, leading to difficulties with coughing, clearing secretions, and maintaining adequate ventilation. This weakness can ultimately result in an increased risk of breathing difficulties, respiratory infections, and respiratory failure. Therefore, clients with these conditions require close monitoring and respiratory support to manage and prevent complications related to respiratory function.
Nurse Kevin is assessing a newborn for developmental dysplasia of the hip (DDH); he would expect to assess which of the following?
- A. Characteristic limp
- B. Ortolani's sign
- C. Symmetrical gluteal folds
- D. Trendelenburg‘s signs
Correct Answer: B
Rationale: Developmental dysplasia of the hip (DDH) is a condition where the hip joint does not properly form in babies and young children. To assess for DDH, healthcare professionals like Nurse Kevin utilize the Ortolani test. Ortolani's sign is a physical exam maneuver where the healthcare provider will gently manipulate the baby's hips to detect if there is a dislocated hip joint. Specifically, the Ortolani maneuver checks for the presence of a "clunk" as the femoral head relocates into the acetabulum, indicating that the hip joint is dislocated. Therefore, during the assessment of a newborn for DDH, Nurse Kevin would expect to assess for Ortolani's sign as it helps in the diagnosis of developmental dysplasia of the hip.
Which of the ff should the nurse include in the teaching plan of a client with acute bronchitis?
- A. Not coughing frequently
- B. Washing the hands frequently
- C. Consuming adequate calories
- D. Encouraging a semi-Fowler's position
Correct Answer: B
Rationale: In acute bronchitis, the highest priority in the teaching plan should focus on preventing the spread of infection. Washing hands frequently can help reduce the risk of spreading the infection to others or introducing new germs that could worsen the client's condition. Proper hand hygiene is one of the most important ways to prevent the transmission of respiratory infections, like bronchitis, by reducing the number of pathogens on the hands. This measure is important not only for the client's well-being but also for the health of those in close contact with the client.