Nokea
A five-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Correct Answer: B
Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure in bacterial meningitis due to inflammation. The other findings are not specific to meningitis in infants.
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A client with angina is experiencing migraine headaches. The physician has prescribed Sumatriptan succinate (Imitrex). Which nursing action is most appropriate?
- A. Call the physician to question the prescription order.
- B. Try to obtain samples for the client to take home.
- C. Perform discharge teaching regarding this drug.
- D. Consult social services for financial assistance with obtaining the drug.
Correct Answer: A
Rationale: Sumatriptan, a triptan, is contraindicated in angina due to vasoconstrictive effects, risking coronary ischemia. Questioning the order (A) is priority. Samples (B), teaching (C), and financial aid (D) are inappropriate without resolving the contraindication.
Which assignment should not be delegated to the licensed practical nurse?
- A. Inserting a Foley catheter
- B. Discontinuing a nasogastric tube
- C. Obtaining a sputum specimen
- D. Starting a blood transfusion
Correct Answer: D
Rationale: Starting a blood transfusion requires RN-level assessment and monitoring due to the risk of transfusion reactions, which is outside the LPN’s scope in most settings. Foley insertion, NG tube discontinuation, and sputum collection are within LPN scope.
The nurse is observing the ambulation of a client recently fitted for crutches. Which observation requires nursing intervention?
- A. Two finger widths are noted between the axilla and the top of the crutch.
- B. The client bears weight on his hands when ambulating.
- C. The crutches and the client's feet move alternately.
- D. The client bears weight on his axilla when standing.
Correct Answer: D
Rationale: Bearing weight on the axilla can cause nerve damage (e.g., brachial plexus injury); crutches should support weight on the hands.
The client tells the nurse, 'I have pain in my left shoulder.' This is considered:
- A. Evaluation process
- B. Objective information
- C. Subjective information
- D. Complaining
Correct Answer: C
Rationale: Subjective information is provided by a person.
A client with a history of chronic kidney disease is admitted with complaints of edema. The nurse should expect the client to have:
- A. Hypernatremia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypokalemia
Correct Answer: C
Rationale: Chronic kidney disease impairs potassium excretion, leading to hyperkalemia, which can cause cardiac complications.