Nokea
A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses the newborn at home 2 days later and finds the weight to be 6 pounds 7 ounces. What should the nurse tell the parents about this weight loss?
- A. The newborn needs additional assessments
- B. The mother should breast feed more often
- C. A change to formula is indicated
- D. The loss is within normal limits
Correct Answer: D
Rationale: The loss is within normal limits. A newborn is expected to lose 5-10% of the birth weight in the first few days post-partum because of changes in elimination and feeding.
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The nurse is caring for a four-year-old child with a closed head injury. The nurse would be reassured by which of the following observations?
- A. The child is able to state his name when asked who he is.
- B. The child reaches for a stuffed animal brought from home.
- C. The child maintains himself in opisthotonos.
- D. The child withdraws from mildly painful stimuli.
Correct Answer: A
Rationale: Stating his name indicates orientation, a positive sign post-head injury. Options B, C, and D are less reassuring: reaching for a toy is nonspecific, opisthotonos suggests meningeal irritation, and withdrawal may occur in unconscious states.
The homecare nurse is visiting a young adult with a diagnosis of hepatitis A. Which of the following statements, if made by the client to the nurse, indicates that further teaching is needed?
- A. I have been very careful to wash my hands after I go to the bathroom.
- B. I have had to take Tylenol several times this week for this sinus infection I have.
- C. I have been very careful not to handle my child's toys or eating utensils.
- D. My husband has been preparing all of the meals since I've been sick.
Correct Answer: B
Rationale: Tylenol (acetaminophen) is hepatotoxic and should be avoided in hepatitis A, which impairs liver function, indicating a need for further teaching. Options A, C, and D show correct precautions to prevent oral-fecal transmission.
When providing nursing measures to relieve a 102-degree Fahrenheit fever in a toddler with an infection, what is the most effective intervention?
- A. Use medications to lower the temperature set point
- B. Apply extra layers of clothing to prevent shivering
- C. Immerse the child in a tub containing cool water
- D. Give a tepid sponge bath prior to giving an antipyretic
Correct Answer: A
Rationale: Use medications to lower the temperature set point. Antipyretics effectively reduce fever by adjusting the hypothalamic set point, preventing complications like seizures.
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin detemir (Levemir) 15 units SC daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue
- B. Sweating and shakiness
- C. Occasional thirst
- D. Mild headache
Correct Answer: B
Rationale: Sweating and shakiness indicate hypoglycemia, a medical emergency with insulin detemir. Options A, C, and D are less urgent: fatigue is nonspecific, thirst is expected, and headache is common.
During an initial interview at an outpatient clinic, a 34-year-old single mother tells the nurse that she has always had difficulty forming relationships and is worried that her 7-year-old daughter will have the same problem. Which of the following statements, if made by the nurse, is BEST?
- A. Children develop trust from birth to 18 months of age.
- B. Children develop trust from 18 months to three years of age.
- C. Children develop trust from three to six years of age.
- D. Children develop trust from six to twelve years of age.
Correct Answer: A
Rationale: Erikson states that trust results from interaction with dependable, predictable primary caretaker