The nurse receives a report on an infant whose analysis indicates 47 total chromosomes, with the abnormality noted at chromosome 21. What additional assessments will the nurse include when evaluating the infant?
a. Cleft palate
b. Protruding tongue
c. Extra fingers or toes (polydactyly)
d. Intellectual developmental delay
ANS: B
Trisomy 21 is associated with a number of notable physical characteristics, including wide-set eyes, flat bridge of the nose, protruding tongue, short neck, small chin, poor muscle tone, and space between the great and second toes. An infant with trisomy 21 tend to be short in stature and developmentally delayed, but two characteristics will become more noticeable as the child gets older. Cleft palate and polydactyly are more common with trisomy 13.
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Which assessment finding by the nurse would be suggestive of a minor burn?
1. The involved skin is deep reddish-brown in color and edematous. 2. Blisters begin to form on the skin within the first hour of exposure. 3. The skin remains intact because only the epidermal layer is involved. 4. Scarring will be evident on the edges of the burn in a matter of hours.
A cognitively impaired patient newly admitted to the hospital is experiencing signs of sundown syndrome. Which intervention is best for the nurse to implement?
a. Leave a night light on in the room at all times. b. Leave the television on at night with the volume up. c. Restrain the patient to maintain safety during the confusion. d. Administer a sleeping medication to help the patient sleep.
A 36-year-old man with lymphoma presents with signs of impending septic shock 9 days after chemotherapy. The nurse could expect which of the following to be present?
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