Nokea
An infant is born with facial abnormalities, growth retardation, mental retardation, and vision abnormalities. These abnormalities are probably caused by maternal:
- A. Alcohol consumption.
- B. Vitamin B6 deficiency.
- C. Vitamin A deficiency.
- D. Folic acid deficiency.
Correct Answer: A
Rationale: These symptoms are characteristic of fetal alcohol syndrome, caused by maternal alcohol consumption during pregnancy, which affects fetal development.
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A nurse who fails to check a client's armband before administering his medications is:
- A. Negligent.
- B. Following standard procedure.
- C. Acting within their scope of practice.
- D. Exercising professional judgment.
Correct Answer: A
Rationale: Failing to check a client's armband before administering medications is negligent, as it violates patient safety protocols for verifying identity.
The nurse is assessing a client with a suspected bowel obstruction. Which of the following findings is most indicative of this condition?
- A. Abdominal distension.
- B. Decreased bowel sounds.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A,B
Rationale: Abdominal distension and decreased bowel sounds are hallmark signs of bowel obstruction due to blocked intestinal passage.
A client diagnosed with multiple sclerosis is prescribed baclofen. Which assessment finding would indicate to the nurse that the client is experiencing a therapeutic response from the medication?
- A. Decreased nausea
- B. Decreased muscle spasms
- C. Increased muscle tone and strength
- D. Increased range of motion of all extremities
Correct Answer: B
Rationale: Baclofen is a skeletal muscle relaxant and acts at the spinal cord level to decrease the frequency and amplitude of muscle spasms in clients with spinal cord injuries or diseases, or multiple sclerosis. None of the other options are related to the effects of this medication.
The nurse is assessing a client who is suspected of being in the early symptomatic stages of human immunodeficiency virus (HIV) infection. Which of the following signs and symptoms of infection should the nurse detect during this stage?
- A. Whitish yellow patches in the mouth.
- B. Dyspnea.
- C. Mild diarrhea.
- D. Raised, hyperpigmented lesions on the legs.
Correct Answer: C
Rationale: Mild diarrhea is a common early symptom of HIV infection, unlike the other options, which appear in later stages.
The nurse reviewing the electrocardiogram (ECG) rhythm strip of a client with a history of a myocardial infarction (MI) notes that the PR intervals are 0.16 seconds. The nurse should arrive at which interpretation of this assessment data?
- A. A normal finding
- B. An abnormal finding
- C. An impending reinfarction
- D. First-degree atrioventricular (AV) block
Correct Answer: A
Rationale: The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The PR interval range is 0.12 to 0.2 seconds. Therefore, the finding is normal. The remaining options all indicate an abnormal finding, so they are not appropriate responses.