Nokea
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.
You may also like to solve these questions
Concerning Ebstein-Barr virus (infectious mononucleosis):
- A. Presence of petechiae between the hard and soft palate supports the diagnosis
- B. Typically a rash following administration of penicillin V occurs
- C. Guillain-Barre syndrome is a recognised sequel
- D. Hepatitis is common
Correct Answer: A
Rationale: Petechiae between the hard and soft palate are a classic sign of infectious mononucleosis. A rash following penicillin V is also common, and Guillain-Barre syndrome is a rare complication.
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.
In Asia, the following hepatitis virus appears to be a significant cause of viral myocarditis
- A. hepatitis E virus
- B. hepatitis B virus
- C. hepatitis C virus
- D. hepatitis D virus
Correct Answer: A
Rationale: Hepatitis E virus has been identified as a significant cause of viral myocarditis in Asia.
Common reasons for doing a BMT in children are:
- A. SCID (severe combined immunodeficiency)
- B. Acute lymphoblastic leukemia
- C. CML
- D. Gaucher's disease
Correct Answer: A
Rationale: The correct answer is A because SCID is a primary indication for bone marrow transplant (BMT) in children. The other options (b-e) are also indications but less common.
Treatment for congestive heart failure (CHF) in an infant began 3 days ago and has included digoxin and furosemide. The child no longer has retractions, lungs are clear, and HR is 96 beats per minute while sleeping. The nurse is confident that the child has diuresed successfully and has good renal perfusion when the nurse notes the child's urine output is:
- A. 0.5 cc/kg/hr
- B. 1 cc/kg/hr
- C. 30 cc/hr
- D. 1 oz/hr
Correct Answer: B
Rationale: Normal pediatric urine output is approximately 1 cc/kg/hr.