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The nurse in a long-term care facility is caring for a client with major depressive disorder who is reporting difficulty sleeping. The client gets up during the night, paces the hallway, wrings the hands, and appears teary. Which of the following actions should the nurse take? Select all that apply.
- A. Arrange for the client to receive at least 20 minutes of natural sunlight each day
- B. Encourage the client to take naps during the day
- C. Instruct the client to engage in physical exercise just before bedtime
- D. Provide the client with a cup of warm milk in the evening
- E. Spend time with the client in a quiet environment just before bedtime
- F. Suggest that the client listen to soft music before going to bed
Correct Answer: A, D, E, F
Rationale: Natural sunlight exposure (A) helps regulate circadian rhythms and improve mood. Warm milk (D) contains tryptophan, which promotes sleep. A quiet environment (E) and soft music (F) reduce stimulation and promote relaxation. Naps (B) may disrupt nighttime sleep, and exercise before bedtime (C) can be stimulating.
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The practical nurse is assisting with care for several newborns in the nursery. Which of the following findings are abnormal and need to be reported to the registered nurse? Select all that apply.
- A. Chest wall retractions
- B. Flaking skin on the feet
- C. Head circumference of 13½ inches (34 cm)
- D. Jaundice of the head and sclera
- E. No documentation of voiding in past 24 hours
Correct Answer: A, D, E
Rationale: Chest retractions (A), jaundice (D), and no voiding (E) are abnormal and require reporting. Flaking skin (B) and head circumference (C) are normal for newborns.
The nurse is giving home care to a 69-year-old client who has severe arthritis. Which comment made by the client would indicate to the nurse that the client is experiencing normal changes associated with the aging process?
- A. I have such a hard time with the pain in my feet and knees.
- B. I have had loose stools for the last few months.
- C. My children say I keep my apartment too warm.
- D. I have a hard time at night because the lights are all big and fuzzy.
Correct Answer: C
Rationale: Feeling cold and preferring a warmer environment is a normal age-related change due to decreased thermoregulation. Pain, loose stools, and visual changes may indicate pathology requiring further investigation.
A client with Addison's disease will most likely exhibit which symptom?
- A. Hypertension
- B. Bronze pigmentation
- C. Hirsutism
- D. Purple striae
Correct Answer: B
Rationale: A bronze pigmentation is a sign of Addison's disease. Answers A, C, and D are symptoms of Cushing's syndrome, making them incorrect.
Laboratory reference ranges
Glucose (random) – newborn < 24 hours old
40-60 mg/dL
(2.2-3.3 mmol/L)
The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings? Select all that apply.
- A. respirations of 56 breaths per minute
- B. capillary glucose of 60 mg/dL (3.3 mmol/L)
- C. holosystolic murmur auscultated at fourth intercostal space
- D. single transverse crease across palm of the hand
- E. white papules on bridge of the nose
Correct Answer: A, B, E
Rationale: Respirations of 56 (A), glucose of 60 mg/dL (B), and white papules (milia) (E) are normal in neonates. A holosystolic murmur (C) and single transverse crease (D) suggest congenital abnormalities.
During the immediate postoperative period after a colostomy, which stoma appearance requires the licensed practical nurse to contact the supervising registered nurse immediately?
- A. Brick red with slight moisture
- B. Dusky moderate edema
- C. Pink with slight oozing of blood
- D. Red with no stool produced
Correct Answer: B
Rationale: A dusky stoma (B) indicates ischemia, requiring immediate reporting. Brick red (A), pink with oozing (C), and no stool (D) are normal post-colostomy findings.