Nokea
The nurse doing a newborn assessment counts the infant's cord vessel.
In a normal infant there are:
- A. Two vessels: one vein and one artery.
- B. Three vessels: two veins and one artery.
- C. Three vessels: one vein and two arteries.
- D. Four vessels: two veins and two arteries.
Correct Answer: C
Rationale: There are three vessels: one vein (carries oxygenated blood to the fetus) and two arteries (return deoxygenated blood to the placenta) in a normal umbilical cord.
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A 12-year-old male is brought to his primary care provider to determine whether sexual abuse has occurred. The mother states, 'Because there is no permanent physical damage, he does not need any more treatment.' The nurse's response should be based on which of the following pieces of information?
- A. Male victims of sexual abuse seldom have long-term psychological problems.
- B. Survivors of male sexual abuse might become confused about their sexual identity.
- C. Unless treated, all male sex abuse survivors grow up to abuse other children.
- D. All children who have been sexually abused have the same needs, regardless of gender.
Correct Answer: B
Rationale: Male sexual abuse survivors may experience confusion about sexual identity, necessitating psychological support. The other statements are incorrect: long-term issues are common, not all survivors become abusers, and needs vary by gender. Psychosocial Integrity
A patient is admitted to the surgical unit with a diagnosis of rule out intestinal obstruction. The nurse is preparing to insert a Salem sump NG tube as ordered. In which of the following positions would it be BEST for the nurse to place this patient during the procedure?
- A. Head of bed elevated 30°-45°.
- B. Head of bed elevated 60°-90°.
- C. Side-lying with head elevated 15°.
- D. Lying flat with head turned to the left side.
Correct Answer: B
Rationale: Positioning the patient with the head of the bed elevated 60°-90° (high Fowler’s position) facilitates swallowing and allows gravity to aid the passage of the nasogastric (NG) tube through the esophagus into the stomach. This position reduces the risk of aspiration and eases tube insertion. Lower elevations (30°-45°), side-lying, or flat positions do not optimize swallowing or tube advancement as effectively.
A child who has recently been diagnosed with cystic fibrosis (CF) is being assessed by a pediatric clinic nurse. Which finding of this disease would the nurse not expect to see at this time?
- A. Positive sweat test
- B. Bulky greasy stools
- C. Moist, productive cough
- D. Meconium ileus
Correct Answer: C
Rationale: Moist, productive cough. Option C is a later sign. Noisy respirations and a dry non-productive cough are commonly the first of the respiratory signs to appear in a newly diagnosed client with CF. The other options are the earliest findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF, a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.
An adult is scheduled for a magnetic resonance imaging (MRI) exam today. Which finding must be reported immediately?
- A. The client has pins in her toes.
- B. The client usually wears a necklace.
- C. The client used to work in the x-ray department.
- D. The client has a pacemaker.
Correct Answer: D
Rationale: Pacemakers are contraindicated for MRI due to magnetic field interference, risking device malfunction, requiring immediate reporting, unlike pins, necklaces, or prior x-ray work.
The nurse is assessing a client with a history of migraines. Which of the following symptoms would the nurse expect the client to report?
- A. Bilateral dull headache.
- B. Photophobia and nausea.
- C. Constant daily headache.
- D. Pain relieved by physical activity.
Correct Answer: B
Rationale: Migraines typically cause unilateral throbbing pain with photophobia and nausea due to neurological sensitivity. Bilateral dull pain (A) suggests tension headache, constant pain (C) indicates chronic headache, and activity (D) worsens migraines.