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A 4-year-old child with Down syndrome is admitted to the hospital with pneumonia. She has a heart murmur and appears to be in respiratory distress. Her mother asks why her child has a heart murmur. What is the best nursing response?
- A. Because she has pneumonia, her heart is working harder and causes the murmur.'
- B. Heart murmurs come and go in children. It is not a great concern.'
- C. Because of the pneumonia, her ductus arteriosus is functioning again.'
- D. Heart defects are common in children with Down syndrome. Her illness may make the murmur louder.'
Correct Answer: D
Rationale: Congenital heart defects, like ventricular septal defects, are common in Down syndrome, and pneumonia may amplify a murmur due to increased cardiac workload.
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A patient with major depressive disorder is prescribed fluoxetine (Prozac). Which of the following instructions should the nurse include?
- A. Take this medication at bedtime.
- B. Avoid drinking grapefruit juice.
- C. It may take several weeks to feel the full effect.
- D. Stop taking the medication if you feel better.
Correct Answer: C
Rationale: Fluoxetine’s full effect takes 4–6 weeks, and patients must continue it to maintain benefits. Bedtime dosing is not standard, grapefruit juice is irrelevant, and stopping early risks relapse.
The nurse is caring for a client with a spinal cord injury at the T4 level. Which of the following findings would be MOST concerning?
- A. Blood pressure of 80/50 mmHg with a pulse of 50.
- B. Temperature of 99°F (37.2°C).
- C. Spasticity in the lower extremities.
- D. Numbness in the hands and fingers.
Correct Answer: A
Rationale: A T4 spinal cord injury can cause autonomic dysreflexia or neurogenic shock, leading to severe hypotension (80/50) and bradycardia (pulse 50), which are life-threatening and require immediate intervention. Low-grade fever (B), spasticity (C), and numbness (D) are expected or less urgent.
A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse's immediate attention?
- A. Capillary refill of fingers on right hand is 3 seconds
- B. Skin warm to touch and normally colored
- C. Client reports prickling sensation in the right hand
- D. Slight swelling of fingers of right hand
Correct Answer: C
Rationale: Client reports prickling sensation in the right hand. A prickling sensation is an indication of compartment syndrome and requires immediate action by the nurse. The other findings are normal for a client in this situation.
A client's vision is to be evaluated using the Ishihara exam. The nurse recognizes that the client will be checked for:
- A. Macular degeneration
- B. Astigmatism
- C. Color blindness
- D. Glaucoma
Correct Answer: C
Rationale: The Ishihara exam tests for color blindness by assessing color perception. It does not evaluate macular degeneration, astigmatism, or glaucoma.
The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions?
- A. 14 minutes
- B. 10 minutes
- C. 15 minutes
- D. 9 minutes
Correct Answer: C
Rationale: 15 minutes. Frequency is measured from the start of one contraction to the start of the next.