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At 1 minute of age, an infant has a heart rate of 95, a strong cry, some flexion of extremities, a cry reflex, and is completely pink. Which of the following is a correct assessment of the infant’s Apgar score?
- A. 4
- B. 6
- C. 8
- D. 10
Correct Answer: C
Rationale: The Apgar score is calculated by adding the scores for heart rate, cry, reflex, extremity movement, and color: 1 + 2 + 1 + 2 + 2 = 8.
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An elderly client’s family asks the nurse to withhold cancer information from the client. Which ethical principle is the nurse upholding by sharing the information?
- A. Justice
- B. Beneficence
- C. Veracity
- D. Nonmaleficence
Correct Answer: C
Rationale: Veracity involves honesty, which requires providing truthful information to the client, facilitating autonomous decision-making.
The proportion of people with a condition who correctly test positive when screened is known as:
- A. Sensitivity
- B. Specificity
- C. Validity
- D. Efficacy
Correct Answer: A
Rationale: Sensitivity is the proportion of true positives correctly identified by a screening test.
An 18-year-old woman in whom a sexually transmitted disease (STD) was recently diagnosed asks the nurse not to tell her mother that she has an STD. Her mother asks the nurse what is causing her daughter’s vaginal discharge. Which of the following actions should the nurse take?
- A. Follow the principle of veracity and tell the mother the diagnosis.
- B. Respect the principle of confidentiality and support the client’s request not to tell her mother the diagnosis.
- C. Tell the client’s mother that she has a urinary tract infection, to protect the client’s privacy and honor the mother’s request.
- D. Ignore the mother’s request for information.
Correct Answer: B
Rationale: The Health Insurance Portability and Accountability Act (HIPAA) guarantees client confidentiality. The nurse must maintain confidentiality unless the client permits disclosure.
Stress related to family dynamics: Who is at risk?
- A. A 54-year-old couple whose daughter and grandson move back in
- B. A 44-year-old single mother raising three children
- C. A 60-year-old couple whose children live in another state
- D. A 36-year-old couple whose child plays competitive tennis
Correct Answer: A
Rationale: Family dynamics involving caregiving or financial stressors increase the risk of stress-related issues.
A nurse is working with a family of an infant to improve their health-perception and health management pattern. Which of the following interventions would be most appropriate for the nurse to implement?
- A. Assess the home for safety hazards.
- B. Teach parents appropriate coping mechanisms.
- C. Demonstrate effective parenting skills.
- D. Encourage appropriate stimulation of the infant.
Correct Answer: C
Rationale: Demonstrating effective parenting skills helps enhance the parents' ability to care for their infant and ensures better health management.