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During an admission physical assessment, the nurse is examining a newborn who is small for gestational age (SGA). Which finding should the nurse report immediately to the pediatric healthcare provider?
- A. Heel stick glucose of 65 mg/dL.
- B. Head circumference of 35 cm (14 inches).
- C. Widened, tense, bulging fontanel.
- D. High-pitched shrill cry.
Correct Answer: C
Rationale: The correct answer is C: Widened, tense, bulging fontanel. This finding is concerning as it can indicate increased intracranial pressure, potentially leading to serious complications in a newborn. The fontanel should be flat or slightly depressed, not bulging. Immediate reporting is necessary for timely intervention.
Incorrect choices:
A: Heel stick glucose of 65 mg/dL is slightly low but not an immediate concern; can be managed with feeding.
B: Head circumference of 35 cm is within the normal range for a newborn and does not require immediate action.
D: High-pitched shrill cry can be a sign of distress but not as urgent as a bulging fontanel in this context.
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A client with a history of diabetes mellitus is admitted with a foot ulcer. The nurse should recognize that which intervention is most critical in promoting healing of the foot ulcer?
- A. Strict control of blood glucose levels.
- B. Regular dressing changes with sterile technique.
- C. Application of antibiotic ointment.
- D. Hydrotherapy treatment daily.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Strict control of blood glucose levels is critical in promoting healing of foot ulcers in diabetic patients.
2. High blood glucose levels can impair wound healing by affecting circulation and immune response.
3. Maintaining normal glucose levels helps optimize tissue repair and prevent further complications.
4. Regular dressing changes (B) are important but not as critical as controlling blood glucose levels.
5. Application of antibiotic ointment (C) may be necessary for infected ulcers, but not the most critical intervention.
6. Hydrotherapy treatment (D) can help with wound cleansing, but it is not as essential as controlling blood glucose levels.
A male client in the day room becomes increasingly angry and aggressive when denied a day-pass. Which action should the nurse implement?
- A. Tell him he can have a day pass if he calms down.
- B. Put the client's behavior on extinction.
- C. Decrease the volume on the television set.
- D. Instruct the client to sit down and be quiet.
Correct Answer: D
Rationale: The correct answer is D because instructing the client to sit down and be quiet is a non-confrontational and calming approach to de-escalate the situation. It helps redirect the client's focus and encourages self-regulation. Choice A may reinforce the aggressive behavior by rewarding it. Choice B (putting behavior on extinction) may escalate the situation further. Choice C (decreasing TV volume) does not address the client's behavior directly.
A client diagnosed with major depressive disorder refuses to get out of bed, eat, or participate in group therapy. Which intervention is most important for the nurse to implement?
- A. Offer the client high-calorie snacks and frequent small meals.
- B. Ask the client why they are not participating in therapy.
- C. Sit with the client and offer support without demanding participation.
- D. Encourage the client to discuss their feelings of hopelessness.
Correct Answer: C
Rationale: The correct answer is C because sitting with the client and offering support without demanding participation is crucial in building trust and rapport. This approach respects the client's autonomy and allows them to feel supported without pressure. It also creates a safe space for the client to open up when they are ready.
Explanation for why the other choices are incorrect:
A: Offering high-calorie snacks and frequent small meals does not address the core issue of the client's refusal to participate in therapy.
B: Asking the client why they are not participating in therapy may come off as confrontational and could further discourage them from opening up.
D: Encouraging the client to discuss their feelings of hopelessness may be overwhelming for them at this stage and could lead to resistance.
The client with a history of heart failure is taking furosemide (Lasix). Which laboratory result should the nurse monitor closely?
- A. Serum sodium.
- B. Serum potassium.
- C. Serum calcium.
- D. Serum magnesium.
Correct Answer: B
Rationale: The correct answer is B: Serum potassium. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Hypokalemia can exacerbate cardiac arrhythmias in patients with heart failure. Monitoring serum potassium levels is crucial to prevent complications.
Incorrect choices:
A: Serum sodium - Furosemide may cause hyponatremia, but it is less critical compared to hypokalemia in a client with heart failure.
C: Serum calcium - Furosemide does not directly affect calcium levels significantly in most cases.
D: Serum magnesium - While furosemide can cause hypomagnesemia, monitoring potassium is more essential in this scenario due to its impact on cardiac function.
A client is admitted with suspected meningitis. Which assessment finding requires immediate intervention?
- A. Headache.
- B. Fever.
- C. Nuchal rigidity.
- D. Seizures.
Correct Answer: D
Rationale: The correct answer is D: Seizures. Seizures in a patient with suspected meningitis indicate increased intracranial pressure, which is a medical emergency requiring immediate intervention to prevent brain damage or herniation. Headache (A), fever (B), and nuchal rigidity (C) are common symptoms of meningitis but do not pose an immediate threat to life like seizures do. Addressing the seizures first is crucial to prevent further complications and ensure the patient's safety.