Nokea
Is head lag expected to be resolved by 4 months of age? Continuing head lag at 6 months of age may indicate?
- A. Dizziness and orthostatic hypotension.
- B. Nausea, vomiting, diarrhea, or constipation, and stomach cramps.
- C. Drowsiness, lethargy, and fatigue.
- D. Neuropathy and tingling in the extremities.
Correct Answer: B
Rationale: Head lag is a developmental milestone that should be resolved by 4 months of age. Continuing head lag at 6 months of age may indicate potential developmental delays or muscle weakness. The correct answer, 'Nausea, vomiting, diarrhea, or constipation, and stomach cramps,' reflects symptoms that could be associated with developmental delays or underlying health conditions. Dizziness and orthostatic hypotension (Choice A) are unlikely to be directly related to head lag. Choices C and D present symptoms that are unrelated to the issue of continued head lag at 6 months of age.
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Which type of hepatitis is transmitted via the fecal-oral route?
- A. Hepatitis A
- B. Hepatitis B
- C. Hepatitis C
- D. Hepatitis D
Correct Answer: A
Rationale: Hepatitis A is the correct answer because it is transmitted via the fecal-oral route, often through contaminated food or water. Hepatitis B is transmitted through exposure to infectious blood, semen, and other body fluids, not through the fecal-oral route. Hepatitis C is transmitted through blood-to-blood contact, not via the fecal-oral route. Hepatitis D occurs only in individuals infected with Hepatitis B. Therefore, the correct choice for the type of hepatitis transmitted via the fecal-oral route is Hepatitis A.
Paula is a 32-year-old woman seeking evaluation and treatment for major depressive symptoms. A major nursing priority during the assessment process includes which of the following?
- A. meaning of current stressors
- B. possibility of self-harm
- C. motivation to participate in treatment
- D. presence of alcohol or other drug use
Correct Answer: B
Rationale: The correct answer is to consider the possibility of self-harm during the assessment process. This is crucial because unless the client is first assessed for self-harm or suicide potential, the necessary degree of vigilance in the client's environment may not be observed. While understanding the meaning of current stressors is important for treatment planning, ensuring the client's safety takes precedence. Motivation to participate in treatment and the presence of alcohol or other drug use are also important aspects to assess but ensuring the client's safety is the top priority in this scenario.
A client goes to the Emergency Department with acute respiratory distress and the following arterial blood gases (ABGs): pH 7.35, PCO2 40 mmHg, PO2 63mmHg, HCO3 23, and oxygenation saturation (SAO2) 93%. Which of the following represents the best analysis of the etiology of these ABGs?
- A. tuberculosis (TB)
- B. pneumonia
- C. pleural effusion
- D. hypoxia
Correct Answer: D
Rationale: A combined low PO2 and low SAO2 indicates hypoxia. The pH, PCO2, and HCO3 are normal. ABGs are not necessarily altered in TB or pleural effusion. In pneumonia, the PO2 and PCO2 might be low because hypoxia stimulates hyperventilation, but the best analysis in this case is hypoxia due to the combination of low PO2 and low SAO2.
Jane Love, a 35-year-old gravida III para II at 23 weeks gestation, is seen in the Emergency Department with painless, bright red vaginal bleeding. Jane reports that she has been feeling tired and has noticed ankle swelling in the evening. Laboratory tests reveal a hemoglobin level of 11.5 g/dL. After evaluating the situation, the nurse determines that Jane is at risk for placenta previa, based on which of the following data?
- A. anemia
- B. edema
- C. painless vaginal bleeding
- D. fatigue
Correct Answer: C
Rationale: Placenta previa is a disorder where the placenta implants in the lower uterine segment, causing painless bleeding in the third trimester of pregnancy. The bleeding results from tearing of the placental villi from the uterine wall as the lower uterine segment contracts and dilates. It can be slight or profuse and can include bright red, painless bleeding. While anemia (choice A) may be a consequence of chronic bleeding from placenta previa, it is not a direct indicator. Edema (choice B) and fatigue (choice D) are nonspecific symptoms that can occur in pregnancy but are not specific to placenta previa.
A nurse gave medications to the wrong client. She stated the client responded to the name called. What is the nurse's appropriate documentation?
- A. Note in medication records the drug given
- B. The client was not hurt, no need for documentation
- C. Note the client's orientation
- D. Completely fill out an incident report
Correct Answer: D
Rationale: In the case where medications are given to the wrong client, the appropriate documentation by the nurse should involve completely filling out an incident report. This report is essential for tracking errors, implementing corrective measures, and ensuring patient safety. Choice A is incorrect because solely noting the drug given does not address the severity of the error. Choice B is incorrect because even if the client was not hurt, documentation is crucial for quality improvement and risk prevention. Choice C is incorrect as noting the client's orientation does not adequately address the medication error and its implications.