Nokea
The nurse assessing a newborn with physiologic jaundice knows that physiologic jaundice is caused by:
- A. Failure of the ductus venosus to close
- B. An immature liver
- C. An ABO incompatibility
- D. A lack of surfactant
Correct Answer: B
Rationale: Physiologic jaundice results from an immature liver's inability to conjugate bilirubin efficiently. Other options are unrelated to physiologic jaundice.
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A laboring woman says to the LPN/LVN, 'My baby is coming! My baby is coming!' She was last checked 15 minutes ago and was 5 cm dilated. What should the LPN/LVN do initially?
- A. Have her checked to see if she has progressed
- B. Reassure her that she cannot be that far along
- C. Reposition her to begin pushing
- D. Request medication to help her relax
Correct Answer: A
Rationale: Urgent reports of delivery sensation require immediate cervical check to confirm progression, as rapid labor can occur, ensuring timely intervention.
The nurse is teaching a school-aged child and family about the use of inhalers prescribed for asthma. What is the best way to evaluate effectiveness of the treatments?
- A. Rely on child's self-report
- B. Use a peak-flow meter
- C. Note skin color changes
- D. Monitor pulse rate
Correct Answer: B
Rationale: The peak flow meter, if used correctly, shows effectiveness of inhalants.
A client has been admitted with complaints of lower abdominal pain, difficulty swallowing, nausea, dizziness, headache and fatigue. The client is agitated, fearful, tachycardic and complains of being 'too sick to return to work.' The client is diagnosed as having somatoform disorder. In formulating a plan of care, the nurse must consider that the client's behavior
- A. Is controlled by their subconscious mind
- B. Is manipulative to avoid work responsibilities
- C. Would respond to psychoeducational strategies
- D. Could be modified through reality therapy
Correct Answer: A
Rationale: Is controlled by their subconscious mind. Somatoform disorder involves involuntary physical complaints driven by psychological factors, not conscious manipulation.
A client going to surgery tells the nurse that she is an active member of the Jehovah's Witness religion. The nurse is aware that the client's spiritual beliefs prohibit:
- A. The use of antibiotics and antivirals
- B. The use of medication from pork sources
- C. The eating of shellfish
- D. The use of blood or blood products
Correct Answer: D
Rationale: Jehovah's Witnesses prohibit blood transfusions and blood products due to religious beliefs. Other options are not typically restricted.
The nurse is caring for a client with a history of diabetes insipidus.
- A. Which symptom is expected in a client with diabetes insipidus?
- B. Weight gain and edema.
- C. Polyuria and thirst.
- D. Hypotension and bradycardia.
- E. Hyperglycemia and fatigue.
Correct Answer: B
Rationale: Polyuria and thirst result from diabetes insipidus due to insufficient antidiuretic hormone, leading to excessive water loss. Weight gain, edema, hypotension, and hyperglycemia are unrelated.