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On assessment of a newborn being admitted to the nursery, the nurse palpates the anterior fontanel and notes that it feels soft. The nurse determines that this finding indicates which condition?
- A. Dehydration
- B. A normal finding
- C. Increased intracranial pressure
- D. Decreased intracranial pressure
Correct Answer: B
Rationale: The anterior fontanel is normally 2 to 3 cm in width, 3 to 4 cm in length, and diamond-like in shape. It can be described as soft, which is normal, or full and bulging, which could indicate increased intracranial pressure. Conversely a depressed fontanel could mean that the infant is dehydrated.
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The nurse is teaching the parents of a child diagnosed with celiac disease about dietary measures. The nurse should instruct the parents to take which measure?
- A. Restrict corn and rice in the diet.
- B. Restrict fresh vegetables in the diet.
- C. Substitute grain cereals with pasta products.
- D. Avoid foods that are hidden sources of gluten.
Correct Answer: D
Rationale: Gluten is found primarily in the grains of wheat, rye, barley, and oats. Gluten is added to many foods as hydrolyzed vegetable protein that is derived from cereal grains; therefore, labels need to be read. Corn and rice, as well as vegetables, are acceptable in a gluten-free diet, and corn and rice become substitute foods. Many pasta products contain gluten.
The nurse monitors a patient with acute pancreatitis. Which assessment finding indicates that paralytic ileus has developed?
- A. Inability to pass flatus
- B. Loss of anal sphincter control
- C. Severe, constant pain with rapid onset
- D. Firm, nontender mass palpable at the lower right costal margin
Correct Answer: A
Rationale: An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. Option 4 is the description of the physical finding of liver enlargement.
A client experiencing a severe major depressive episode is unable to address activities of daily living (ADL). Which nursing intervention best meets the client's current needs therapeutically?
- A. Have the client's peers approach the client about how noncompliance in addressing ADL affects the milieu.
- B. Structure the client's day so that adequate time can be devoted to the client's assuming responsibility for ADL.
- C. Offer the client choices and describe the consequences for the failure to comply with the expectation of maintaining her or his own ADL.
- D. Feed, bathe, and dress the client as needed until the client's condition improves so that she or he can perform these activities independently.
Correct Answer: D
Rationale: The symptoms of major depression include depressed mood, loss of interest or pleasure, changes in appetite and sleep patterns, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, diminished ability to think or concentrate, and recurrent thoughts of death. Often, the client does not have the energy or interest to complete activities of daily living. Option 1 will increase the client's feelings of poor self-esteem and of unworthiness. Option 2 is incorrect because the client still lacks the energy and motivation to do these independently. Option 3 may lead to increased feelings of worthlessness as the client fails to meet expectations.
The nurse is admitting a client with a diagnosis of hypothyroidism. What assessment should the nurse perform to obtain data related to this diagnosis?
- A. Inspect facial features.
- B. Auscultate lung sounds.
- C. Percuss the thyroid gland.
- D. Inspect ability to ambulate safely.
Correct Answer: A
Rationale: Inspection of facial features will reveal the characteristic coarse features, presence of edema around the eyes and face, and the blank expression that are characteristics of hypothyroidism. The assessment techniques in options 2, 3, and 4 will not reveal information related to the diagnosis of hypothyroidism.
A client is scheduled for computed tomography (CT) of the kidneys to rule out renal disease. Which should the nurse assess the client for before the procedure to best assure the client's safety?
- A. Allergies
- B. Familial renal disease
- C. Frequent antibiotic use
- D. Long-term diuretic therapy
Correct Answer: A
Rationale: The client undergoing any type of diagnostic testing involving possible dye administration should be questioned about allergies, specifically an allergy to shellfish or iodine. This is essential to identify the risk for potential allergic reaction to contrast dye, which may be used.