Nokea
A Jewish client requests an orthodox diet while she is hospitalized. The nurse should refer this request to the:
- A. Dietitian
- B. Physician
- C. Unit case manager
- D. Rabbi in pastoral care
Correct Answer: A
Rationale: The dietitian is responsible for addressing dietary requests, including religious preferences like an orthodox Jewish diet, to ensure nutritional needs are met. The physician, case manager, or rabbi may not specialize in dietary planning.
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The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the chart below. The nurse compares these findings to the Apgar score obtained at birth, as determined by the findings in the chart below. What should the nurse do next?
- A. Notify the neonatologist on call.
- B. Continue to assess the neonate.
- C. Apply an oxygen mask.
- D. Rub the neonate's extremities.
Correct Answer: B
Rationale: Without specific Apgar score data, the standard action is to continue assessing the neonate, as Apgar scores at 5 minutes guide ongoing monitoring unless critical findings are present.
A client asks the nurse why he was asked to complete an advance directive when he entered the hospital. The nurse's best response is which of the following?
- A. This will provide a substitute for informed discussion with the physician.'
- B. It is a legal requirement for all clients entering a hospital to be offered the chance to make an advance directive.'
- C. The physician will make the best decisions for you in an emergency.'
- D. Are you worried that extraordinary means will be taken if you are dying?'
Correct Answer: B
Rationale: It is a legal requirement in many regions for hospitals to offer patients the opportunity to complete an advance directive upon admission to ensure their wishes are documented.
A client with a history of multiple sclerosis is admitted with muscle weakness. The nurse should include which of the following in the plan of care?
- A. Assist with activities of daily living.
- B. Restrict physical activity.
- C. Provide a high-carbohydrate diet.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Assisting with activities of daily living supports safety and independence in multiple sclerosis.
During a home visit, the nurse is evaluating an infant for auditory ability. Which of the following is the expected response in an infant with normal hearing?
- A. Stoppage of body movements when sound is introduced.
- B. Evidence of shy and withdrawn behaviors.
- C. Saying 'da-da' by age 5 months.
- D. Absence of squealing by age 4 months.
Correct Answer: A
Rationale: Infants with normal hearing typically pause or stop movements in response to sound, indicating auditory awareness.
A client with a history of stroke is prescribed clopidogrel (Plavix). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Bruising.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Bruising may indicate bleeding, a serious side effect of clopidogrel, an antiplatelet medication, requiring immediate reporting.