Nokea
A veteran is admitted with a diagnosis of chronic post-traumatic stress disorder. After being placed in the treatment room, he begins to pace frantically and make references to 'highway one.' As the nurse approaches him, he retreats to the corner and sits on the floor with his arms and legs pulled tight to his body. The client is experiencing a:
- A. Hallucination
- B. Phobic reaction
- C. Delusion
- D. Flashback
Correct Answer: D
Rationale: The behavior and reference to 'highway one' suggest a flashback, where the client is reliving a traumatic event, common in PTSD.
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The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
- A. Unequal leg length
- B. Limited adduction
- C. Diminished femoral pulses
- D. Symmetrical gluteal folds
Correct Answer: A
Rationale: Unequal leg length. Shortening of the affected leg is a sign of developmental dysplasia of the hip.
A 2-year-old child seen in the emergency department is dehydrated and malnourished. The child’s parent reports that the child has had diarrhea for the past 2 weeks. Which observation is of most concern to the nurse?
- A. The parent cannot stay at the hospital due to potential job loss if late for work
- B. The parent does not seem to be concerned about the child’s condition
- C. The parent is single
- D. The parent left a 3-year-old and a 5-year-old in the care of a 9-year-old
Correct Answer: D
Rationale: Leaving young children in the care of a 9-year-old poses significant safety risks, indicating neglect and requiring immediate intervention. Job constraints, lack of concern, and single status are concerning but less immediately dangerous.
On initial examination of a 15 month-old child with suspected otitis media, which group of findings would the registered nurse (RN) anticipate?
- A. Periorbital edema, absent light reflex and translucent tympanic membrane
- B. Irritability, rhinorrhea, and bulging tympanic membrane
- C. Diarrhea, fever, and reddened tympanic membrane
- D. Vomiting, pulling at ears and pearly white tympanic membrane
Correct Answer: B
Rationale: Irritability, rhinorrhea, and bulging tympanic membrane. These findings are characteristic of otitis media, indicating infection and inflammation of the middle ear.
The nurse is preparing the sterile field and supplies for a wet-to-damp dressing change. Which of the following actions by the nurse would require follow-up?
- A. Drop sterile gauze on the sterile field from 6 inches (15cm ) above
- B. Keeps the sterile field and sterile gloved hands within view at all times
- C. Places sterile gauze 2 inches (5 cm) inside the outer edge of the sterile drape
- D. Pours sterile saline solution from a recapped bottle opened 30 hours ago
Correct Answer: D
Rationale: Using saline from a bottle opened 30 hours ago risks contamination, as sterile solutions are typically discarded after 24 hours. Keeping the field in view and placing gauze appropriately maintain sterility.
The obstetric client is determined to have oligohydramnios. Which fetal anomaly is associated with oligohydramnios?
- A. Diabetes
- B. Renal agenesis
- C. Tracheo-esophageal fistula
- D. Tracheo-esophageal atresia
Correct Answer: B
Rationale: Oligohydramnios, low amniotic fluid, is strongly associated with renal agenesis, as the fetus's kidneys fail to produce urine, a major component of amniotic fluid. Other anomalies listed are less directly related.