Question

1. "We should probably test your son's immune system."
2. "There are many different type of CF, and they affect different people differently."
3. "Are you certain you have been following his medication schedule exactly?"
4. "Children have different levels of disease because they have differing amounts of dysfunction in the gene that causes CF."

Answer 1

4
Rationale 1: If the frequency of illness is the only assessment finding, it is not necessary to test the child's immune system.
Rationale 2: This statement is not factual and does not explain the difference in the son's illness.
Rationale 3: The nurse should not imply that the son's frequent illnesses are the mother's fault.
Rationale 4: The greater the alteration in the CFTR gene, the more severe the symptoms associated with CF.

Answer 2

2
Rationale 1: The Denver II is a screening tool used to assess personal-social, fine motor adaptive, language, and gross motor skills in children between birth and 6 years of age.
Rationale 2: The nurse should use the Mini-Mental Status Examination to gather more information about the cognitive status of this client. This tool is also useful to estimate cognitive impairment as well as to track cognitive changes over time.
Rationale 3: The Life Experiences Survey is used to evaluate the level of stress an individual is experiencing; this is not appropriate for this client's concerns.
Rationale 4: The Hassles and Uplifts Scale measures attitudes about daily situations; it does not screen for cognitive changes.

Answer 3

1,2,3,4
Rationale 1: Inspection. The nurse would visually inspect the knee's general appearance including the presence or redness, swelling and dislocation. The knee's appearance would be contrasted with the unaffected knee.
Rationale 2: Palpation. The area would be palpated for tenderness and warmth.
Rationale 3: Bulge sign testing. The bulge sign test is used to detect the presence of small amounts of fluid (4 to 8 ml) in the suprapatellar bursa. The test involves placing the client in the supine position and then using firm pressure to stroke the medial aspect of the knee upward several times, displacing any fluid. As the pressure is applied to the lateral side of the knee the medial side is observed for bulging.
Rationale 4: Ballottement. Ballottement is a technique used to detect fluid, or to examine or detect floating body structures. The nurse displaces body fluid and then palpates the return impact of the body structure.
Rationale 5: Percussion. Percussion is the use of tapping actions by the examiner. This tapping elicits sounds that can be evaluated for tone and depth to detect the presence of abnormalities. Percussion is normally utilized to assess the lungs and abdominal cavity. It is not used to assess for knee injuries.

Answer 4

1,2,3,5
Rationale 1: For the client to inherit an autosomal recessive disorder, his mother must have the disorder or be a carrier for it.
Rationale 2: Each sibling has a 50% chance of being a carrier and a 25% chance of developing the disease.
Rationale 3: For the client to inherit an autosomal recessive disorder, his father must have the disorder or be a carrier for it.
Rationale 4: The client's children have a 50% chance of being affected.
Rationale 5: As this client has manifested the disorder, it is clear he inherited two recessive genes. The father must contribute one gene to each child, so it must be a recessive gene, making the children carriers. If the children's mother also has the disorder or is a carrier, the children's chances of developing the disorder are higher.

Answer 5

3
Rationale 1: When a room is dark, the client's pupils should dilate in response.
Rationale 2: Pupil constriction occurs as the client focuses on the paper. It does not indicate the client can read.
Rationale 3: This is a normal finding. The client's pupils should constrict in response to trying to read what is on the paper.
Rationale 4: Pupil constriction would not lead the nurse to believe the client needs reading glasses.