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A nurse is caring for a 1-month-old client who is being evaluated for congenital hypothyroidism. The nurse should recognize which of the following as clinical manifestations of hypothyroidism in infants? Select all that apply.
- A. Difficult to awaken
- B. Dry skin
- C. Frequent, loose stools
- D. Hoarse cry
- E. Tachycardia
Correct Answer: A,B,D
Rationale: Hypothyroidism in infants causes lethargy (A), dry skin (B), and hoarse cry (D) due to slowed metabolism. Loose stools (C) and tachycardia (E) are more typical of hyperthyroidism.
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A client with asthma was recently prescribed fluticasone/salmeterol. After the client has received instructions about this medication, which statement would require further teaching by the nurse?
- A. After taking this medication, I will rinse my mouth with water.'
- B. At the first sign of an asthma attack, I will take this medication.'
- C. I have been smoking for 12 years, but I just quit a month ago.'
- D. I received the pneumococcal vaccine about a month ago.'
Correct Answer: B
Rationale: Fluticasone/salmeterol is a maintenance medication for asthma, not a rescue inhaler for acute attacks. Statement B indicates a misunderstanding, requiring further teaching to clarify that a short-acting bronchodilator (e.g., albuterol) should be used for acute symptoms. Rinsing the mouth (A) prevents oral thrush from the steroid component. Quitting smoking (C) and receiving a vaccine (D) are positive health behaviors not requiring correction.
The nurse is discussing dementia with the families of older adults. All of the following behaviors are reported. Which behavior is most suggestive of dementia?
- A. The woman can't remember the birth year of each of her six children.
- B. A woman walked to the store and got lost on the way home.
- C. A woman forgot where she put her purse.
- D. A man is wearing one green sock and one red sock and doesn't see the difference.
Correct Answer: B
Rationale: Getting lost in a familiar area indicates significant spatial disorientation, a hallmark of dementia. Forgetting details, misplacing items, or color oversight are less specific.
Which of the following activities is most suitable for a 10-year old with asthma?
- A. Soccer
- B. Swimming
- C. Basketball
- D. Constructing model cars
Correct Answer: B
Rationale: Swimming is ideal for children with asthma, as the humid environment reduces airway irritation, unlike high-exertion sports like soccer or basketball.
The nurse is talking with the parent of a 15-month-old client who is scheduled to receive the varicella vaccine. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
- A. Your child may develop a low-grade fever after receiving the vaccine
- B. Your child can have aspirin to decrease discomfort caused by the vaccine.
- C. Your child may develop a rash at the injection site after receiving the vaccine.
- D. Your child will require a second dose of the vaccine at a subsequent visit.
- E. Your child should not receive any other vaccines at the same visit.
Correct Answer: A,C,D
Rationale: The varicella vaccine may cause a low-grade fever (A) or a rash at the injection site (C) as common side effects. A second dose (D) is required at 4-6 years for full immunity. Aspirin (B) is contraindicated in children due to Reye’s syndrome risk. Other vaccines (E) can be given concurrently, per CDC guidelines, unless contraindicated.
The nurse is floated from the obstetrical (OB) floor to the medical/surgical floor. Which client is the best assignment for the OB nurse?
- A. Female client with a fractured pelvis who is 4 months pregnant
- B. Female client with cytomegalovirus pneumonia
- C. Male client with an open bowel resection with a Foley catheter
- D. Male client with history of Billroth II surgery who is septic
Correct Answer: A
Rationale: The OB nurse’s expertise in pregnancy care makes the pregnant client with a fractured pelvis (A) the best assignment, as it aligns with their skills in managing maternal-fetal health. Other clients (B, C, D) require general medical-surgical care unrelated to OB.