Nokea
The nurse is assessing a dark-skinned client with anemia. Which part of the body would the nurse assess for pallor?
- A. Nail beds
- B. Hard palate
- C. Sclera
- D. Buccal mucosa
Correct Answer: D
Rationale: The buccal mucosa is reliable for assessing pallor in dark-skinned clients, as skin pigmentation may mask changes elsewhere.
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The nurse has received her assignment for the day and is to care for the following clients. Which client should the nurse go to first?
- A. A 56-year-old who was admitted last evening vomiting blood; the night nurse says he has had no emesis for the last four hours
- B. A 65-year-old who had hip replacement surgery two days ago
- C. A 68-year-old who fell yesterday and is scheduled for hip surgery later this morning
- D. A 69-year-old who was admitted last evening with severe right upper quadrant and right scapular pain
Correct Answer: A
Rationale: The client with recent hematemesis is at risk for recurrent bleeding, requiring immediate assessment to ensure stability, prioritizing over stable surgical or presurgical clients.
While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age?
- A. They are able to make simple association of ideas
- B. They are able to think logically in organizing facts
- C. Interpretation of events originate from their own perspective
- D. Conclusions are based on previous experiences
Correct Answer: B
Rationale: They are able to think logically in organizing facts. The child in the concrete operations stage is capable of mature thought when organizing objects.
Which of the following infants is in need of additional growth assessment?
- A. Baby girl A: age 4 months, BW 7 lbs. 6 oz., present weight 14 lbs. 14 oz.
- B. Baby girl B: age 2 weeks, BW 6 lbs. 10 oz., present weight 6 lbs. 11 oz.
- C. Baby girl C: age 6 months, BW 8 lbs. 9 oz., present weight 15 lbs. 0 oz.
- D. Baby girl D: age 2 months, BW 7 lbs. 2 oz., present weight 9 lbs. 10 oz.
Correct Answer: B
Rationale: Baby B has gained only 1 oz. in 2 weeks, indicating poor growth (normal is 0.5-1 oz./day). Others show appropriate weight gain.
A client with pernicious anemia is admitted. What would the nurse expect the admitting assessment to reveal?
- A. Ecchymoses on the trunk
- B. Bilateral neuropathy of the legs
- C. Decreased platelet count
- D. Decreased appetite
Correct Answer: B
Rationale: Pernicious anemia, a vitamin B12 deficiency, often causes neurological symptoms like bilateral leg neuropathy due to nerve demyelination.
The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?
- A. Stand on 1 foot
- B. Catch a ball
- C. Skip on alternate feet
- D. Ride a bicycle
Correct Answer: A
Rationale: Stand on 1 foot. Balancing on one foot is expected by age 3, indicating gross motor delay if absent.