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The nurse correctly explains that, during adolescence, being with a peer group and mimicking peer behaviors is part of the process of achieving which developmental task?
- A. Identity
- B. Intimacy
- C. Integrity
- D. Idealism
Correct Answer: A
Rationale: Adolescence involves developing a sense of identity, often through peer group interactions and mimicking behaviors, as teens explore their place in the world.
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If the nurse collects the following data, which assessment finding best indicates the presence of increased intracranial pressure?
- A. Rapid bilateral pupillary response to light
- B. Tympanic temperature of 97.9°F (36.6°C)
- C. Blood pressure of 150/90 mm Hg
- D. Deep tendon reflexes +2
Correct Answer: C
Rationale: Elevated blood pressure (e.g., 150/90 mm Hg) is a sign of increased intracranial pressure, often part of Cushing's triad (hypertension, bradycardia, irregular respirations), indicating brain compression.
The nurse is completing the 1-minute Apgar assessment on the full-term newborn. The newborn’s HR is 80 bpm. What should the nurse do next?
- A. Assign a 2 for the Apgar score that pertains to the heart rate.
- B. Suction the excess secretions from the newborn’s oral cavity.
- C. Wrap in warm blankets and place on the mother’s abdomen.
- D. Begin immediate positive pressure ventilation on the newborn.
Correct Answer: D
Rationale: A newborn HR of less than 100 bpm scores as a 1 on the HR criterion and indicates a need to begin positive pressure ventilation by bag mask or Neopuff® ventilation. A score of 2 requires HR above 100 bpm. Suctioning is not indicated and wrapping is done after assessment.
The nurse is admitting a neonate after delivery who is diagnosed with a myelomeningocele. Which intervention should the nurse implement immediately?
- A. Positions the infant prone and covers the sac with sterile gauze.
- B. Notifies the surgeon on call that the infant is ready for surgery.
- C. Applies a pressure dressing to the sac and starts an intravenous access.
- D. Positions the infant prone,hips slightly flexed and legs abducted.
Correct Answer: D
Rationale: Positioning prone with hips flexed and legs abducted minimizes sac tension and rupture risk. Sterile gauze risks adherence surgery follows stabilization and pressure dressings risk rupture.
Which medication instruction provided by the nurse is most accurate?
- A. Taking your acyclovir as prescribed will prevent the recurrence of lesions.
- B. Your sex partners also need to be treated for 10 days with oral acyclovir.
- C. Use a glove to apply topical acyclovir.
- D. Take the oral acyclovir even when the disease is in remission.
Correct Answer: C
Rationale: Using a glove to apply topical acyclovir prevents self-contamination and virus spread, making it an accurate and safe instruction.
Pregnancy induced hypertension is diagnosed when:
- A. Hypertension is encountered after 20 weeks of gestation.
- B. Hypertension gets worse in first week of pregnancy.
- C. Hypertension is not controlled with aldomet.
- D. Hypertension gives rise to left ventricular failure.
- E. Blood urea & creatine levels in blood are abnormal.
Correct Answer: A
Rationale: Pregnancy-induced hypertension (gestational hypertension) is diagnosed when hypertension (BP ≥140/90 mmHg) appears after 20 weeks gestation without proteinuria or other preeclampsia features.