Nokea
The nurse is assessing a 1-month-old infant with atrial septal defect. Which of the following findings would be consistent with the condition?
- A. cyanosis
- B. muffled heart tones
- C. murmur
- D. weak femoral pulses
Correct Answer: C
Rationale: An atrial septal defect often presents with a heart murmur due to abnormal blood flow. Cyanosis is rare unless severe, muffled tones are not typical, and weak femoral pulses suggest coarctation of the aorta.
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The nurse is assessing a newborn delivered at home by a client addicted to heroin. Which of the following would the nurse expect to observe?
- A. Hypertonic neuro reflex
- B. Immediate CNS depression
- C. Lethargy and sleepiness
- D. Jitteriness at 24-48 hours
Correct Answer: D
Rationale: Jitteriness at 24-48 hours. Withdrawal signs may not be evident for 1-2 days after birth. Irritability and poor feeding also are evident.
An adult client in an acute care setting asks the nurse to show him his hospital records. The nurse's response should reflect which understanding?
- A. The client has no right to see his records without a court order.
- B. The client must have the physician's approval before he can see his records.
- C. The client has the right to see his records and to have information explained when necessary.
- D. The client must ask permission to view his records from the medical records department and must appear before a special committee.
Correct Answer: C
Rationale: HIPAA grants clients the right to access their medical records and receive explanations, ensuring transparency. Court orders, physician approval, or committees are not required.
A client who has a known history of cardiac problems and is still smoking enters the clinic complaining of sudden onset of sharp, stabbing pain that intensifies with a deep breath. The pain is occurring on only one side and can be isolated upon general assessment. The nurse concludes that this description is most likely caused by:
- A. pleurisy.
- B. pleural effusion.
- C. atelectasis.
- D. tuberculosis.
Correct Answer: A
Rationale: Pleurisy is an inflammation of the pleura and is often accompanied by abrupt onset of pain. Symptoms of pleurisy are abrupt pain that is usually unilateral and localized to a specific portion of the chest.
The nurse is collecting data from a client who had a transurethral resection of the prostate 10 hours ago and is receiving continuous bladder irrigation. Which of the following findings would require follow-up?
- A. blood pressure of 114/70 mm Hg and heart rate of 66/min
- B. reports relief of bladder spasms after administration of oxybutynin
- C. light pink urine is noted in the catheter tubing and urinary drainage bag
- D. bladder irrigation input of 3000 mL and urine output of 2800 mL over the past 4 hours
Correct Answer: D
Rationale: A 200 mL discrepancy between irrigation input and output suggests possible catheter obstruction or absorption, requiring follow-up. Normal vitals , spasm relief , and light pink urine are expected post-TURP.
What socioeconomic indicators would the nurse identify as risk factors for a 2-month-old infant to develop failure to thrive (FTT)? Select all that apply.
- A. Both caregivers work outside the home
- B. Infant lives only with mother, who is currently unemployed
- C. Infant's primary caregiver has cognitive disabilities
- D. Parents are socially and emotionally isolated
- E. Parents live together but are not married
Correct Answer: B,C,D
Rationale: Risk factors for FTT include unemployment limiting resources, caregiver cognitive disabilities impairing care, and social/emotional isolation reducing support. Working parents and unmarried status are not direct risks.