Nokea
A 2-month-old infant has been admitted to the hospital with suspected shaken baby syndrome (abusive head trauma). In reviewing the infant's chart, the nurse expects to encounter which of these clinical findings?
- A. A reported history of recent trauma
- B. Abdominal bruising
- C. External signs of trauma
- D. Irritability and vomiting
Correct Answer: D
Rationale: Shaken baby syndrome often presents with irritability and vomiting due to intracranial injury, without external trauma , abdominal bruising , or reported trauma .
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A nurse at outpatient clinic is returning phone calls that have been made to the clinic. Which of the following calls should have the highest priority for medical intervention?
- A. A home health patient reports, 'I am starting to have breakdown of my heels.'
- B. A patient that received an upper extremity cast yesterday reports, 'I can't feel my fingers in my right hand today.'
- C. A young female reports, 'I think I sprained my ankle about 2 weeks ago.'
- D. A middle-aged patient reports, 'My knee is still hurting from the TKR.'
Correct Answer: B
Rationale: The patient experiencing neurovascular changes should have the highest priority. Pain following a TKR is normal, and breakdown over the heels is a gradual process. Moreover, a subacute ankle sprain is almost never a medical emergency.
A client is taking lithium for management of bipolar I disorder. The client's most recent serum lithium level is 0.8 mEq/L (0.8 mmol/L). Based on this result, what prescription does the nurse anticipate receiving from the health care provider?
- A. Continue at the current dose
- B. Decrease the dose
- C. Discontinue the medication
- D. Increase the dose
Correct Answer: D
Rationale: A lithium level of 0.8 mEq/L is low (therapeutic range: 1.0-1.5 mEq/L for acute mania). Increasing the dose is likely to achieve therapeutic levels.
The nurse is reinforcing discharge instructions to a client who has had coronary artery bypass grafting. Which teachings are correct? Select all that apply.
- A. No sexual activity for at least 6 weeks postoperatively
- B. Notify the health care provider (HCP) of redness, swelling, or drainage at the incision site
- C. Refrain from lifting objects weighing >5 lb (2.25 kg) until approved by the HCP
- D. Take a shower daily without soaking chest and leg incisions
- E. Use lotion on incision sites when changing dressing if the areas are dry
Correct Answer: B,C,D
Rationale: Reporting infection signs , weight restrictions , and daily showers are correct. Sexual activity can resume earlier if stable, and lotion is not routine.
The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care?
- A. Encourage the client to cough and deep breathe every 2 hours
- B. Place the client in contact isolation
- C. Provide a diet high in protein
- D. Institute seizure precautions
Correct Answer: A
Rationale: Encourage the client to cough and deep breathe every 2 hours. Coughing and deep breathing prevent respiratory infections due to shallow respirations.
A client is admitted with a lower urinary tract infection from an obstructing ureteral stone. Which tasks can the nurse delegate to the experienced unlicensed assistive personnel? Select all that apply.
- A. Collecting a urine specimen for culture and sensitivity
- B. Frequent turning and repositioning of the client
- C. Measuring and documenting urine output
- D. Monitoring the color and characteristics of urine output
- E. Teaching the client to strain urine while voiding
Correct Answer: B,C
Rationale: Turning and measuring output are within UAP scope. Collecting specimens , monitoring characteristics , and teaching require nursing judgment.