Nokea
A neonatal nurse assesses a premature newborn baby using the Apgar score. All of the following assessments are given a score EXCEPT
- A. grimace.
- B. pulse.
- C. activity.
- D. rooting.
- E. appearance.
Correct Answer: D
Rationale: The Apgar score evaluates appearance, pulse, grimace, activity, and respiration. Rooting (a feeding reflex) is not part of the Apgar assessment.
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A manic client is admitted to an inpatient psychiatric center. He is hyperactive, talking quickly, acting aggressively, and pacing. The nursing staff should
- A. outline realistic expectations for the client's behavior.
- B. ignore the client's behavior.
- C. allow the client to eat lunch with other clients to observe the interaction.
- D. assign an RN to stay with the client at all times.
Correct Answer: D
Rationale: A manic client’s behavior requires close supervision for safety. Assigning an RN to stay with the client ensures monitoring and intervention as needed.
The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
- A. I will make sure I eat breakfast within 2 hours of taking my insulin.
- B. I will need to carry candy or some form of sugar with me all the time.
- C. I will eat a snack around three o'clock each afternoon.
- D. I can save my dessert from supper for a bedtime snack.
Correct Answer: C
Rationale: NPH insulin peaks 4-12 hours after administration, so a snack around 3 PM helps prevent hypoglycemia during peak action.
A client with AIDS has a viral load of 200 copies per ml. The nurse should interpret this finding as:
- A. The client is at risk for opportunistic diseases.
- B. The client is no longer communicable.
- C. The client's viral load is extremely low so he is relatively free of circulating virus.
- D. The client's T-cell count is extremely low.
Correct Answer: C
Rationale: A viral load of 200 copies/ml is low, indicating effective treatment and minimal circulating virus.
The nurse is caring for a client with suspected AIDS dementia complex. The first sign of dementia in the client with AIDS is:
- A. Changes in gait
- B. Loss of concentration
- C. Problems with speech
- D. Seizures
Correct Answer: B
Rationale: Loss of concentration is an early cognitive change in AIDS dementia complex.
A client has been instructed in the application and use of anti-embolic compression stockings. Which of the following statements by the client indicates a need for more teaching? Select all that apply.
- A. After I apply the stocking, I roll the top back down about 2 inches to hold the stockings in place.
- B. I remove the stocking and reapply about every day or two.
- C. To apply, I turn the stocking inside out while holding onto the toe.
- D. I apply a small amount of baby powder to my legs before applying the stockings.
- E. These stockings help prevent blood clots.
Correct Answer: A,B,D
Rationale: Rolling the top down (A) can impede circulation, removing stockings every 1-2 days (B) is too infrequent (should be every 8 hours), and baby powder (D) can cause skin irritation. Turning the stocking inside out (C) and preventing clots (E) are correct.