Nokea
A newborn baby exhibits a reflex that includes: hand opening, abducted and extended extremities following a jarring motion. Which of the following correctly identifies the reflex?
- A. ATNR reflex
- B. Startle reflex
- C. Grasping reflex
- D. Moro reflex
Correct Answer: D
Rationale: The moro reflex has all of the listed characteristics.
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An advance directive is written and notarized according to law in the state of Colorado. This document is legal and binding:
- A. internationally.
- B. in the state of Colorado only.
- C. in the continental United States.
- D. in the county of origination only.
Correct Answer: B
Rationale: Advance directive protocols and documents are defined by each state.
An LPN is talking with a client scheduled to undergo a vasectomy in the next few minutes. He states, 'I know I signed the form and all, but I'm not feeling so sure of this. It can be reversed pretty easily, right?' What is the LPN's best response?
- A. Yes, vasectomies can be reversed, but I'm sure once you have it you won't regret it.'
- B. It's normal to feel a little nervous before a procedure like this one.'
- C. It sounds like you have a few more questions you'd like answered. Let me grab the doctor to answer them for you.'
- D. It sounds like you might be a little nervous. Don't worry, this is a pretty minor procedure, and the doctor doing it is the best we have. You're in great hands.'
Correct Answer: C
Rationale: This is the only option that validates the client's concerns and also respects his right to informed consent.
A legal right to confidentiality of client information is waived when:
- A. a court system subpoenas information.
- B. a family member requests health care information of a client.
- C. a living will takes effect.
- D. the client is declared incompetent by the legal system.
Correct Answer: A
Rationale: The legal right to confidentiality is waived when the court requires information for legal proceedings, when the state requires mandatory reporting, when a client reveals intent to harm, or when a client cannot make safe decisions.
A client is refusing to stay in the hospital because he does not agree with his healthcare treatment plan. The nurse stops the client from leaving due to concern for his health. Which of these legal charges could the nurse face?
- A. False imprisonment, as the nurse is not allowing the client to leave as he has decided to.
- B. Malpractice, as the nurse is intentionally keeping the patient from making his own decisions, thus violating that nursing duty.
- C. Invasion of privacy, as the nurse is getting involved in the patient's private decisions regarding healthcare.
- D. Negligence, as the nurse ignored the clients right to choose with regard to his healthcare.
Correct Answer: A
Rationale: Refusing to let a client leave against medical advice (AMA) is a form of false imprisonment and is a legal issue for nurses.
A client states, 'I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?' The nurse should respond with which of the following statements?
- A. Sleep at least 6-8 hours a night
- B. Practice monthly self-breast examination
- C. Reduce stress
- D. All of the above
Correct Answer: D
Rationale: All listed actions contribute to cancer prevention: adequate sleep supports immune function, self-breast exams aid early detection, and stress reduction enhances overall health. These complement the client's existing healthy habits.