Nokea
Which of the following physical findings indicates that an 11-12-month-old child is at risk for developmental dysplasia of the hip?
- A. refusal to walk
- B. not pulling to a standing position
- C. negative Trendelenburg sign
- D. negative Ortolani sign
Correct Answer: B
Rationale: The correct answer is 'not pulling to a standing position.' An 11-12-month-old child not pulling to a standing position may be at risk for developmental dysplasia of the hip. By this age, children typically pull to a standing position, and failure to do so should raise concerns. Refusal to walk is a broader observation and not specific to hip dysplasia. The Trendelenburg sign indicates weakness of the gluteus medius muscle, not hip dysplasia. The Ortolani sign is used to detect congenital subluxation or dislocation of the hip, which is different from developmental dysplasia of the hip.
You may also like to solve these questions
A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?
- A. administering immune globulin intravenously
- B. assessing the extremities for edema, redness, and desquamation every 8 hours
- C. explaining progression of the disease to the client and their family
- D. assessing heart sounds and rhythm
Correct Answer: C
Rationale: Educating the client and their family about the progression of Kawasaki disease is crucial for promoting a positive body image. By explaining when symptoms are expected to improve and resolve, the client and family can better understand that there will be no permanent disruption in physical appearance that could negatively impact body image. Administering immune globulin intravenously is a treatment for Kawasaki disease but does not directly address body image concerns. Assessing the extremities for edema, redness, and desquamation every 8 hours is important for monitoring the disease but does not directly address body image concerns. Assessing heart sounds and rhythm is essential for evaluating cardiac effects of Kawasaki disease but is not the most direct measure for promoting a positive body image.
When obtaining a health history on a menopausal woman, which information should a nurse recognize as a contraindication for hormone replacement therapy?
- A. family history of stroke
- B. ovaries removed before age 45
- C. frequent hot flashes and/or night sweats
- D. unexplained vaginal bleeding
Correct Answer: D
Rationale: When considering hormone replacement therapy for a menopausal woman, unexplained vaginal bleeding should be recognized as a contraindication. This is because it could be indicative of a serious underlying condition that needs investigation before initiating hormone therapy. A family history of stroke, by itself, is not a contraindication for hormone replacement therapy, unless the woman herself has a history of stroke or blood-clotting events. Ovaries removed before age 45 may actually increase the likelihood of needing hormone replacement therapy due to early menopause. Frequent hot flashes and night sweats, on the other hand, are symptoms that can be relieved by hormone replacement therapy, making them a potential indication rather than a contraindication.
An LPN is reviewing medication lists for several clients recently admitted to the hospital. Which of the following scenarios would be least concerning?
- A. A client taking allopurinol for gout states they have been taking black cohosh to help with post-menopausal symptoms.
- B. A client has an order for warfarin and states they have been taking Ginkgo biloba to improve their memory.
- C. A client taking Lipitor states they have been taking ginseng for an energy boost.
- D. A client has a prescription for an SSRI and states they have been taking St. John's wort to also help with their depression.
Correct Answer: C
Rationale: The least concerning scenario is when a client taking Lipitor states they have been taking ginseng for an energy boost. While ginseng may cause an increased risk of bleeding, it should not interact with Lipitor. On the other hand, St. John's wort should not be taken with an SSRI as it may cause serotonin syndrome, posing a more serious concern. Black cohosh should not be taken with allopurinol as they can both cause hepatotoxicity, especially in combination. Ginkgo biloba should not be taken with warfarin as it causes an increased risk of bleeding, making it a more concerning scenario compared to the client taking Lipitor and ginseng.
When administering a nasal spray medication, what should the client do before the medication is administered?
- A. The client should blow their nose gently before the medication is administered.
- B. The medication should be sprayed into the nostril.
- C. The medication should be administered as the client inhales.
- D. The client should sit upright when the medication is administered.
Correct Answer: A
Rationale: The correct answer is that the client should blow their nose gently before the medication is administered. This step helps clear the nasal passages, ensuring that the medication can reach its intended target. Choice B is incorrect as the nasal spray should be directed into the nostril, not just in front of the nose. Administering the medication as the client inhales (Choice C) is crucial to ensure proper delivery, as it helps the medication reach the desired areas. Choice D is incorrect because the client should be sitting upright, not lying flat, when administering nasal spray medication to allow for better absorption and prevent the medication from flowing out.
When a client who is 25 years of age asks the nurse when she should seek fertility counseling, the best response by the nurse is:
- A. "Fertility counseling should be sought when you have been unable to conceive after 1 year of unprotected intercourse."?
- B. "Fertility counseling should be sought when you have not been able to conceive after 6-9 months of unprotected intercourse."?
- C. "The average time it takes someone your age to conceive is 5.3 months, so if you haven't conceived by then, we can refer you."?
- D. "We can give you some guidance now on how to increase your chances of conceiving and then refer you if it doesn't happen within a year."?
Correct Answer: D
Rationale: The best response in this scenario is to offer immediate guidance while also indicating when fertility counseling should be sought. While Choice A is technically correct as guidelines recommend seeking fertility counseling after 1 year of unprotected intercourse, it lacks providing immediate guidance. Choice B suggests seeking counseling after 6-9 months, which is earlier than the standard recommendation of 1 year. Choice C mentions the average time to conceive for someone of the client's age without addressing the client's current concern. Therefore, Choice D is the most appropriate response as it offers immediate guidance along with a plan for referral if needed.