Nokea
A 3-month-old infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action?
- A. Document a description of the injury
- B. Question the parent about where the infant sleeps
- C. Report the injury per facility protocol
- D. Separate the parent from the infant
Correct Answer: C
Rationale: A spiral fracture in a non-mobile infant is inconsistent with rolling off a bed, suggesting abuse. Reporting is the priority to ensure safety. Documentation , questioning , and separation follow.
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A football player is well paid for his superior athletic ability. Described by his friends as quiet and brooding, on the field he is known for his overly aggressive plays. The client's behavior is an example of:
- A. Displacement
- B. Conversion
- C. Sublimation
- D. Repression
Correct Answer: C
Rationale: Sublimation involves channeling emotions (e.g., aggression) into socially acceptable outlets, like sports. Displacement, conversion, and repression do not fit.
A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago. She is 8 weeks pregnant. Which description of her obstetric history is written correctly?
- A. Gravida 4 para 2
- B. Gravida 2 para 1
- C. Gravida 3 para 1
- D. Gravida 3 para 2
Correct Answer: C
Rationale: Gravida 3 para 1. Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).
As adult is admitted with bleeding esophageal varices, and a triple-lumen nasogastric tube is inserted and the balloons inflated. What should the nurse keep at the bedside because the client has this tube?
- A. Adhesive tape
- B. A syringe with water
- C. Scissors
- D. A clamp
Correct Answer: C
Rationale: Scissors are kept at the bedside to cut and release the tube if the balloons cause airway obstruction or excessive pressure, a critical safety measure for triple-lumen tubes like the Sengstaken-Blakemore.
At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. She asks about preconception diet changes. Which of the statements made by the nurse is best?
- A. Include fibers in your daily diet.
- B. Increase green leafy vegetable intake.
- C. Drink milk for the calcium content.
- D. Eat foods rich in folic acid.
Correct Answer: D
Rationale: Eat foods rich in folic acid. Folic acid is essential for preventing neural tube defects in the developing fetus, making it a critical preconception dietary recommendation.
The nurse is collecting data from a 2-week-old client who has tetralogy of Fallot. Which of the following findings would be a priority to follow up?
- A. cyanosis resolves in the knee-chest position
- B. weight gain of 0.6 lb (0.27 kg) since birth
- C. hematocrit level of 67% (0.67)
- D. murmur noted on auscultation
Correct Answer: C
Rationale: Elevated hematocrit indicates polycythemia, a serious complication of tetralogy of Fallot. Knee-chest relief , weight gain , and murmurs are expected.