Nokea
A parent brings her 3 month-old into the clinic, reporting that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment?
- A. increased temperature and lethargy
- B. restlessness and increased mucus production
- C. increased sleeping and listlessness
- D. diarrhea and poor skin turgor
Correct Answer: B
Rationale: This infant could be experiencing gastroesophageal reflux, or could be allergic to the formula. Restlessness, irritability and increased mucus production can develop if an allergy is present.
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The nurse is caring for a hospitalized client diagnosed with thyrotoxicosis (thyroid storm). Which action is most appropriate to assign to unlicensed assistive personnel?
- A. Call the family to give an update on new aspects of the client's condition
- B. Lower the temperature in the room to make the environment cooler
- C. Reinforce teaching about signs and symptoms of hyperthyroidism
- D. Take vital signs and place a warming blanket on the client
Correct Answer: B
Rationale: Lowering room temperature (B) is within UAP scope and helps manage hyperthermia. Calling family (A), teaching (C), and applying a warming blanket (D) are inappropriate or require nursing judgment.
Which test for diabetes measures the long-term management of the disease?
- A. Fasting blood sugar
- B. Glucose tolerance test
- C. Finger stick glucose test
- D. Glycosylated hemoglobin
Correct Answer: D
Rationale: Glycosylated hemoglobin (HbA1c) measures average blood glucose over 2-3 months, assessing long-term diabetes control, unlike fasting, tolerance, or finger stick tests, which are short-term.
Which of the following infractions can result in the revocation of the nurse's license?
- A. Failure to render care during a natural disaster
- B. Suspected negligence
- C. A felony conviction
- D. Failure to pay license renewal fees
Correct Answer: C
Rationale: A felony conviction can lead to license revocation due to its impact on professional integrity. Natural disaster response, negligence, or unpaid fees may have other consequences but are less likely to cause revocation.
The nurse is talking with a client with major depressive disorder who has been taking paroxetine for the past 3 weeks. Which of the following statements by the client would require immediate follow-up?
- A. I have had a decreased appetite lately.'
- B. I still feel depressed even though I have more energy.'
- C. I sometimes have difficulty falling asleep at night.'
- D. I have had a decreased interest in sexual activity recently.'
Correct Answer: B
Rationale: Persistent depression with increased energy (B) may indicate rising suicide risk, requiring immediate follow-up. Appetite (A), sleep (C), and libido (D) changes are common side effects.
The nurse is preparing to administer several medications through a client's feeding tube. None of the medications are extended release. Which of the following actions should the nurse implement? Select all that apply.
- A. Combine all medications and administer together
- B. Crush each medication separately before administration
- C. Determine if the medications are available in liquid form
- D. Flush the tube before and after medication administration
- E. Mix medications with enteral feeding formula before administration
Correct Answer: B, C, D
Rationale: Crushing separately (B) prevents interactions, liquid forms (C) are preferred, and flushing (D) ensures patency. Combining all medications (A) or mixing with formula (E) can cause clogs or interactions.