Nokea
A client who just delivered is concerned about her neonate's Apgar scores of 7 at 1 minute and 8 at 5 minutes. She has been told a score lower than 9 is associated with learning disabilities. Which response is best?
- A. Your infant is fine. Don't worry.
- B. Apgar scores indicate a need for extra medical care at birth. Your baby's score of 7 is fine.
- C. There are many good special education programs available I can recommend.
- D. I'll ask the physician to speak with you.
Correct Answer: B
Rationale: Apgar scores of 7 and 8 are within normal limits, indicating no immediate need for extra care, and this response addresses the mother's concern accurately without dismissing it.
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A client with paranoid schizophrenia has an order for Thorazine (chlorpromazine) 400 mg orally twice daily. Which of the following symptoms should be reported to the physician immediately?
- A. Fever, sore throat, weakness
- B. Dry mouth, constipation, blurred vision
- C. Lethargy, slurred speech, thirst
- D. Fatigue, drowsiness, photosensitivity
Correct Answer: A
Rationale: Fever, sore throat, and weakness may indicate agranulocytosis, a serious side effect of chlorpromazine requiring immediate reporting.
A 20-year-old male has recently been diagnosed with schizophrenia. The nurse knows which of the following are classic signs and symptoms of this disorder? Select all that apply.
- A. social withdrawal
- B. agitation
- C. auditory hallucinations
- D. disorganized speech
- E. obsession with personal hygiene
Correct Answer: A,C,D
Rationale: Schizophrenia symptoms include social withdrawal, auditory hallucinations, and disorganized speech. Agitation may occur but is less specific, and obsession with hygiene is not typical.
A pediatric nurse volunteers at a health screening fair. The nurse examines a patient. Which of the following findings may be indicative of type 1 diabetes and require further investigation?
- A. stomach bloating, swollen lymph nodes, increased thirst
- B. sudden weight loss, blurry vision, muscle weakness
- C. sudden weight gain, ringing in the ears, difficulty sleeping
- D. feeling hungry all of the time, increased thirst, waking up at night to urinate
Correct Answer: D
Rationale: Type 1 diabetes presents with polyphagia, polydipsia, and polyuria (e.g., waking to urinate). Weight loss (B) is also common, but D is the most specific.
The nurse is caring for a client with a permanent tracheostomy who is able to eat. Which is the correct action by the nurse in managing this tube?
- A. if the tube must be capped, place the cap before deflating the cuff
- B. inflate the cuff and remove the inner cannula before capping the tube
- C. inflate the cuff (if the tube is not capped) for meals and 1 hour afterward to prevent aspiration
- D. deflate the cuff (if the tube is not capped) for meals and 1 hour afterward to prevent aspiration
Correct Answer: D
Rationale: Deflating the cuff during meals allows normal swallowing, reducing aspiration risk, and is maintained for 1 hour post-meal.
Following insertion of a nasogastric (NG) tube, the nurse aspirates the gastric contents to check the pH to determine if the NG tube is correctly placed. Which of the following pH values is consistent with gastric secretions?
- A. 8
- B. 6
- C. 5
- D. 4
Correct Answer: D
Rationale: Gastric secretions typically have a pH of 1.5-3.5, so a pH of 4 (D) is consistent with correct NG tube placement in the stomach. Higher pH values (A, B, C) suggest placement in the intestines or respiratory tract.