Nokea
After teaching a mother about the neonate's positive Babinski's reflex, the nurse determines that the mother understands the instructions when she says that a positive Babinski's reflex indicates:
- A. Possible partial paralysis.
- B. Possible lower limb defect.
- C. Immature central nervous system.
- D. Possible injury to nerves that innervate the legs.
Correct Answer: C
Rationale: A positive Babinski's reflex in neonates indicates an immature central nervous system, a normal finding that typically disappears by 1–2 years.
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A client with chronic kidney disease prescribed a protein restrictive diet should be instructed by the nurse to select which incomplete protein option for inclusion in her or his diet? Select all that apply.
- A. Fish
- B. Eggs
- C. Milk
- D. Nuts
- E. Grains
Correct Answer: D,E
Rationale: The client whose diet has a protein restriction should be careful to ensure that the proteins eaten are incomplete proteins with the highest biological value. Nuts and grains are the only options that are not complete proteins. Foods such as meat, fish, milk, and eggs are complete proteins, which are not recommended for the client with chronic kidney disease.
A client with a history of heart failure is admitted with shortness of breath. The nurse should place the client in which of the following positions?
- A. Supine.
- B. Prone.
- C. Fowler's position.
- D. Trendelenburg position.
Correct Answer: C
Rationale: Fowler's position (semi-sitting) promotes lung expansion and reduces cardiac workload in heart failure clients with shortness of breath.
A postmenopausal client with an intact uterus asks the nurse why her hormone medicine has two drugs, estrogen and progesterone. Which of the following statements by the nurse provides the client with accurate information?
- A. The progesterone will help prevent cervical cancer
- B. The progesterone will help prevent breast cancer
- C. The progesterone will help prevent liver disease
- D. The progesterone will help prevent endometrial cancer
Correct Answer: D
Rationale: Progesterone in hormone replacement therapy is used to prevent endometrial hyperplasia and cancer in women with an intact uterus. It does not primarily prevent cervical, breast, or liver disease.
A client with Parkinson's disease is prescribed levodopa-carbidopa (Sinemet). The nurse should instruct the client to:
- A. Take the medication on an empty stomach.
- B. Avoid vitamin B6 supplements.
- C. Take the medication with a high-protein meal.
- D. Stop the medication if dizziness occurs.
Correct Answer: B
Rationale: Vitamin B6 can reduce the effectiveness of levodopa, so clients should avoid B6 supplements.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via nasal cannula. The nurse notes the client's oxygen saturation is 88%. What should the nurse do first?
- A. Increase the oxygen flow to 4 L/min.
- B. Notify the physician immediately.
- C. Encourage the client to perform deep breathing exercises.
- D. Reposition the client to a high Fowler's position.
Correct Answer: D
Rationale: Repositioning to a high Fowler's position optimizes lung expansion and improves oxygenation, which is the first non-invasive intervention to try for a COPD client with low oxygen saturation.