Nokea
A 2-month-old infant has been brought to the ED. Which finding by the nurse would raise suspicion for shaken baby syndrome?
- A. failure to track with the eyes
- B. crying without tear production
- C. bruising to the arms and shoulders
- D. greater-than-expected head circumference and bulging fontanels
Correct Answer: D
Rationale: Bulging fontanels and increased head circumference (D) suggest intracranial hemorrhage, a hallmark of shaken baby syndrome in infants.
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An elderly man is admitted to the ED during the night shift. He reports slipping and hitting his forehead on the bathtub several hours earlier. The nurse is assessing the client's frontal lobe function. Which of the following questions/statements should the nurse ask the client?
- A. Tell me when you feel me touch your arm.
- B. Tell me when you stop hearing the tuning fork sound.
- C. Do you have problems with balance?
- D. How much is two plus four plus seven?
Correct Answer: D
Rationale: The frontal lobe handles executive functions like calculation. Asking a math question (D) assesses this. Touch (A) tests parietal, hearing (B) tests temporal, and balance (C) tests cerebellar function.
The nurse is caring for a client who just had an arteriovenous (AV) fistula placed for dialysis. The nurse is providing home care instructions to the client. Which statement by the client indicates a need for further teaching by the nurse?
- A. I should avoid wearing a watch on my arm with the fistula.
- B. It may take several weeks before the fistula is ready to use.
- C. I should not have my blood pressure taken in my access arm.
- D. I should wear tight sleeves to protect and support the fistula so I don't bend it.
Correct Answer: D
Rationale: Tight sleeves can compress the AV fistula, impairing blood flow, indicating a need for further teaching. Other statements are correct.
The nurse is performing an admission assessment on a client with thrombocytopenia. Which signs and symptoms and lab findings would the nurse expect to see in this client? Select all that apply.
- A. epistaxis
- B. petechiae
- C. vomiting blood
- D. elevated hematocrit
- E. increased platelet count
Correct Answer: A,B
Rationale: Thrombocytopenia causes bleeding tendencies like epistaxis (A) and petechiae (B). Vomiting blood (C) is less common, and hematocrit (D) and platelets (E) are decreased, not elevated.
The nurse is caring for a client with a history of cirrhosis of the liver. Lab values reveal rising ammonia levels. Which of the following actions should the nurse anticipate performing? Select all that apply.
- A. replace electric razor with a straight razor
- B. encourage frequent periods of rest
- C. instruct on a potassium-restricted diet
- D. monitor the client's mental status
Correct Answer: B,D
Rationale: Rising ammonia in cirrhosis causes encephalopathy, so rest (B) and monitoring mental status (D) are needed. Straight razors (A) increase bleeding risk, and potassium restriction (C) is unrelated.
The nurse is preparing to perform a focused abdominal assessment on a client. Which is the correct order of this assessment?
- A. inspection, auscultation, palpation, percussion
- B. inspection, palpation, percussion, auscultation
- C. inspection, percussion, auscultation, palpation
- D. inspection, percussion, palpation, auscultation
Correct Answer: A
Rationale: The correct order is inspection, auscultation, palpation, percussion to avoid altering bowel sounds with palpation or percussion before auscultation.