Nokea
The labor and delivery nurse notes that the health care provider has rated a newborn's Apgar score as 9. The nurse understands which to be true regarding Apgar scores?
- A. The optimum score is 10.
- B. A baby with poor activity would rate a 1 in that area.
- C. The highest score that each factor may receive is 3.
- D. Scores are obtained 5 minutes after birth and repeated 5 minutes later.
Correct Answer: A
Rationale: The optimal Apgar score is 10. Each factor scores 0-2, and scores are taken at 1 and 5 minutes post-birth.
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A client is diagnosed with thromboangiitis obliterans (Buerger's disease). The nurse places priority on teaching the client about modifications of which risk factor related to this disorder?
- A. Exposure to heat
- B. Cigarette smoking
- C. Diet low in vitamin C
- D. Excessive water intake
Correct Answer: B
Rationale: Buerger's disease is an occlusive disease of the median small arteries and veins. It occurs predominantly among men who are more than 40 years old who smoke cigarettes. A familial tendency is noted, but cigarette smoking is consistently a risk factor. Symptoms of the disease improve with smoking cessation. Exposure to heat, diet low in vitamin C, and excessive water intake are not risk factors.
The community health is conducting a health screening clinic. The nurse interprets that which client participating in the screening is the highest priority client to provide instruction to lower the risk of developing respiratory disease?
- A. A smoker who works in an acute care hospital
- B. A person who works with lawn care pesticides
- C. A person who does woodworking as a hobby for 8 years
- D. A smoker who has cracked asbestos lining on the basement pipes
Correct Answer: D
Rationale: The client who smokes and has exposure to cracked asbestos lining is at the highest risk for respiratory disease due to the combined effects of smoking and asbestos, both potent lung irritants. Smoking alone or other exposures (pesticides, woodworking) pose risks, but the dual exposure in option D is the most severe.
The nurse provides home care instructions to a client who has been diagnosed with recurrent trichomoniasis. The nurse determines the need for follow-up teaching if the client indicates she should take which action?
- A. Avoid sexual intercourse.
- B. Perform good perineal hygiene.
- C. Use the metronidazole as prescribed.
- D. Discontinue treatment during menstruation.
Correct Answer: D
Rationale: Treatment for a recurrent vaginal trichomoniasis infection continues through the menstrual period because the vagina is more alkaline during menses, and a flare-up is more likely to occur. While the infection remains active, the client should refrain from sexual intercourse or instruct her partner to wear a condom. To help break the chain of infection, the nurse directs the client to perform perineal hygiene after each voiding and each bowel movement. Metronidazole must be taken as prescribed.
The nurse teaches a client diagnosed with a spinal cord injury about measures to prevent autonomic hyperreflexia. Which statement by the client indicates the need for additional teaching?
- A. It is best if I avoid tight clothing and lumpy bedclothes.
- B. I should watch for headache, congestion, and flushed skin.
- C. Signs/symptoms I should watch for include fever and chest pain.
- D. I need to pay close attention to how frequently my bowels move.
Correct Answer: C
Rationale: Autonomic hyperreflexia generally occurs in a client with a spinal cord injury after the period of spinal shock resolves. It occurs with injuries above T6 and cervical injuries. Signs/symptoms of autonomic hyperreflexia include headache, congestion, flushed skin above the level of injury and cold skin below it, diaphoresis, nausea, and anxiety. Fever and chest pain are not associated with this condition.
The nurse is reviewing the assessment data of a client. Which finding is most important for the client to modify to lessen the risk for coronary artery disease (CAD)?
- A. Elevated triglyceride levels
- B. Elevated serum lipase levels
- C. Elevated serum testosterone level
- D. Elevated low-density lipoprotein (LDL) levels
Correct Answer: D
Rationale: Elevated LDL levels are most directly linked to CAD, as they contribute to atherosclerosis. Triglycerides are a risk factor but less predictive, lipase is unrelated to CAD, and low testosterone, not high, may influence CAD risk.