Nokea
A 6-month-old infant is being seen in the doctor's office. Which observation by the nurse should be brought to the physician's attention?
- A. The baby sits up but needs slight support.
- B. The baby was 7 lb at birth and now weighs 10 lb.
- C. The baby frequently drops objects and looks for them.
- D. The baby smacks her lips and drools.
Correct Answer: B
Rationale: A 6-month-old should double birth weight (14 lb expected for 7 lb); 10 lb suggests poor growth, requiring evaluation. Other findings are developmentally normal.
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The nurse is caring for a client who just had a total thyroidectomy. Which finding does the nurse recognize as most important to report immediately?
- A. Elevated blood pressure
- B. Heart rate irregularity
- C. Low oxygen saturation
- D. Noisy breathing
Correct Answer: D
Rationale: Noisy breathing post-thyroidectomy may indicate airway obstruction from hematoma or edema, a life-threatening emergency. Other findings are less immediately critical but still require monitoring.
The nurse is assessing a 12 year-old who has hemophilia A. Which finding would the nurse anticipate?
- A. An excess of red blood cells
- B. An excess of white blood cells
- C. A deficiency of clotting factor VIII
- D. A deficiency of clotting factors VIII and IX
Correct Answer: C
Rationale: Hemophilia A is characterized by an absence or deficiency of Factor VIII.
The nurse is caring for a client with Cushing's syndrome. The nurse should carefully assess the client for signs of:
- A. Hypoglycemia
- B. Infection
- C. Hypovolemia
- D. Hyperinsulinemia
Correct Answer: B
Rationale: Cushing's syndrome causes immunosuppression, increasing infection risk . Hypoglycemia , hypovolemia , and hyperinsulinemia are not primary concerns.
The physician has ordered an irrigation of the client's left ear for the removal of cerumen. To prevent vestibular stimulation, the fluid should be degrees Fahrenheit:
- A. 68
- B. 76
- C. 98
- D. 120
Correct Answer: C
Rationale: Cerumen is removed using a mixture of water and hydrogen peroxide at body temperature. Answers A and B are incorrect because they are too cold. Answer D is incorrect because it is too hot.
The nurse understands that during the 'tension building' phase of a violent relationship, when the batterer makes unreasonable demands, the battered victim may experience feelings of
- A. Anger
- B. Helplessness
- C. Calm
- D. Explosiveness
Correct Answer: B
Rationale: Helplessness. Victims feel depressed and helpless despite efforts to please the batterer.