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.
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A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. What action should the nurse take first?
- A. Notify the healthcare provider
- B. Assure the client that such feelings occur with wound infections
- C. Visualize the abdominal incision
- D. Obtain sterile towels soaked in saline
Correct Answer: C
Rationale: Visualizing the incision helps determine if dehiscence or evisceration has occurred, which requires immediate intervention.
The differential in a 5-year old with a 2-week history of painful joints is all the following except:
- A. Viral polyarthritis
- B. Rheumatoid arthritis
- C. Lyme disease
- D. Rheumatic fever
Correct Answer: B
Rationale: rheumatoid arthritis is rare in a 5-year-old with a 2-week history of joint pain. The other options (a-d) are more likely differentials.
The parents of a child, age 6, who will begin school in the fall ask the nurse for anticipatory guidance. The nurse should explain that a child of this age:
- A. Still depends on the parents
- B. Rebels against scheduled activities
- C. Is highly sensitive to criticism
- D. Loves to tattle
Correct Answer: C
Rationale: A 6-year-old child is typically highly sensitive to criticism as they are developing self-esteem and are influenced by feedback from adults and peers.
In autism:
- A. Social interaction is normal
- B. Dopamine levels are reduced
- C. Genetic factors may play a role in aetiology
- D. Methylphenidate is used with benefit
Correct Answer: C
Rationale: Genetic factors may play a role in aetiology: Autism spectrum disorder (ASD) has a strong genetic component, with numerous genes contributing to its development, although environmental factors may also play a role.
Emergency management of acute asthma includes:
- A. Arterial blood gas
- B. Nebulised steroids
- C. Intravenous theophylline
- D. Nebulised ~-antagonists
Correct Answer: D
Rationale: Nebulised beta-antagonists are a key part of the emergency management of acute asthma. Arterial blood gas, nebulised steroids, and intravenous theophylline are also used but are not the first line.