Nokea
A newborn baby exhibits a reflex that includes: hand opening, abducted and extended extremities following a jarring motion. Which of the following correctly identifies the reflex?
- A. ATNR reflex
- B. Startle reflex
- C. Grasping reflex
- D. Moro reflex
Correct Answer: D
Rationale: The moro reflex has all of the listed characteristics.
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To manage time most effectively, the nurse responds to which of the following stimuli first:
- A. the physician's loud verbal direction.
- B. the nursing supervisor who is going to a meeting.
- C. unit staff leaving on a break.
- D. the care needs of the returning postoperative client just exiting the elevator.
Correct Answer: D
Rationale: While many environmental stimuli might compete for attention and time, the client care needs of complex or unstable clients and those requiring assessment and care must take priority.
Which of the following factors can impact an individual's ability to give informed consent?
- A. IQ
- B. educational level
- C. pain medications
- D. financial status
Correct Answer: C
Rationale: Pain medications might alter alertness, thought processes, and reactions. It is recommended that a client be approached for consent at least 4 hours after the last dose of pain medicine to allow minimal impact. IQ and educational levels might have a bearing on how information is presented through the discussion process, but they do not have a bearing on informed-consent decision-making.
Which of the following statements is true about a post-discharge follow-up?
- A. The nurse should ensure the client is educated on their discharge instructions.
- B. If the client seems stable, they likely do not need a follow-up visit.
- C. The physician is responsible for making sure the client has their prescriptions upon discharge.
- D. If the client has questions, the nurse should instruct the client to bring them up at their follow-up appointment.
Correct Answer: A
Rationale: The nurse is responsible for ensuring the client is educated, they have their prescriptions, and all their questions are addressed prior to discharge. A client should always have a follow-up visit scheduled with their provider.
Which is the best way to position a client's neck for palpation of the thyroid?
- A. flexed toward the side being examined
- B. hyperextended directly backward
- C. flexed away from the side being examined
- D. flexed directly forward
Correct Answer: A
Rationale: Flexing the neck toward the side being examined relaxes the sternocleidomastoid muscle, making the thyroid gland more accessible for palpation.
A client is refusing to stay in the hospital because he does not agree with his healthcare treatment plan. The nurse stops the client from leaving due to concern for his health. Which of these legal charges could the nurse face?
- A. False imprisonment, as the nurse is not allowing the client to leave as he has decided to.
- B. Malpractice, as the nurse is intentionally keeping the patient from making his own decisions, thus violating that nursing duty.
- C. Invasion of privacy, as the nurse is getting involved in the patient's private decisions regarding healthcare.
- D. Negligence, as the nurse ignored the clients right to choose with regard to his healthcare.
Correct Answer: A
Rationale: Refusing to let a client leave against medical advice (AMA) is a form of false imprisonment and is a legal issue for nurses.