Nokea
The nurse informs the client that acquired immunodeficiency syndrome (AIDS) is commonly associated with which symptoms?
- A. Increased appetite and chills during the night
- B. Tachycardia, dyspnea, and constipation
- C. Fatigue, fever, and persistent yeast infections
- D. Weight gain, peripheral edema, and jaundice
Correct Answer: C
Rationale: AIDS is associated with fatigue, fever, and persistent infections like yeast infections due to immune suppression, making these symptoms characteristic.
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The nurse is assessing the full-term Caucasian infant who is 40 hours old. Which technique should the nurse use to evaluate the infant for jaundice?
- A. Remove the infant’s diaper and look at the color of the genitalia.
- B. Apply pressure on the forehead for 3 seconds,release and evaluate the skin color.
- C. Assess the color of the palms and compare that skin color to the color of the soles.
- D. Open the infant’s mouth to assess the color of the infant’s tongue and palate.
Correct Answer: B
Rationale: To differentiate jaundice from normal skin color apply pressure over a bony area like the forehead. A yellow blanched area indicates jaundice. Genitalia palms soles or oral mucosa are less reliable due to slower progression or darker pigmentation.
Which of the following test is used in screening for Down's syndrome:
- A. Ca 125.
- B. Carcino embryonic antigen CAE.
- C. Triple screening including β HCG,AFP,serum estriol.
- D. FSH,LH.
- E. Thyroid hormone.
Correct Answer: C
Rationale: The triple screen (β-hCG AFP serum estriol) is used in the second trimester to screen for Down syndrome. Other tests are not relevant for this purpose.
A healthy postpartum mother who is breastfeeding her term infant tells the nurse that she has noticed that her roommate is feeding iron-enriched formula to her newborn. The mother asks if she should be giving her baby supplemental iron. Which response by the nurse is correct?
- A. “Your breast milk provides all the iron your baby needs.”
- B. “You,not your baby will need an iron supplement daily.”
- C. “Your pediatrician will prescribe iron drops for your baby.”
- D. “You should feed your baby iron-fortified formula once daily.”
Correct Answer: A
Rationale: Breast milk provides sufficient highly bioavailable iron for term infants making supplementation unnecessary. Maternal iron supplements or formula feeding are not required.
The nurse meets the frantic father at an ED door. He says he just delivered his wife’s full-term newborn in the car when the temperature outside is only 10°F (—12.2°C). In response to the cold environment,the nurse knows that the infant’s body will immediately begin to produce heat by which mechanism?
- A. Shivering
- B. Metabolizing body fat
- C. Dilating surface blood vessels
- D. Decreasing flexion of the extremities
Correct Answer: B
Rationale: When skin receptors of full-term newborns perceive a drop in environmental temperature the sympathetic nervous system is stimulated. This in turn stimulates metabolism of brown fat thus producing heat that is transferred to the peripheral circulation. Shivering is rarely seen in newborns and it does little to produce heat. Newborns conserve heat by constricting not dilating blood vessels. Decreasing flexion promotes heat loss by exposing more skin surface.
Which statement by the child indicates a need for further teaching about bicycle safety?
- A. I'll wear my helmet whenever I ride my bicycle.
- B. I'll ride my bicycle in the opposite direction of traffic flow.
- C. I'll stop at all intersections and look both ways before proceeding.
- D. I won't ride my bicycle after dark on the street.
Correct Answer: B
Rationale: Riding in the opposite direction of traffic flow is unsafe, increasing collision risk. Bicycles should be ridden with traffic flow, indicating a need for further teaching.