Nokea
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.
You may also like to solve these questions
In response to a call for assistance by a client in labor, the nurse notes that a loop of the umbilical cord protrudes from the vagina. What is the priority nursing action?
- A. call the health care provider
- B. check fetal heart load
- C. put the client in knee-chest position
- D. turn the client to the side
Correct Answer: C
Rationale: Immediate action is needed to relieve pressure on the cord, which puts the fetus at risk due to hypoxia. The knee-chest position accomplishes this. The exposed cord is covered with saline-soaked gauze, not reinserted.
A client with Alzheimer disease is admitted to the hospital. The client's adult child says to the nurse, 'I really want to continue caring for my mother at home, but she has become agitated and restless at night. I am awake most of the night, feel exhausted, and do not know what to do.' What is the best response by the nurse?
- A. Do not let your mother take naps in the afternoon.'
- B. Our social worker can discuss supportive options with you.'
- C. We can ask the health care provider for medication that will help your mother sleep.'
- D. Your mother should be cared for in a skilled nursing facility.'
Correct Answer: B
Rationale: Referring to a social worker provides access to resources like respite care or home support, addressing the caregiver's exhaustion. Limiting naps or medication may help but are narrow, and suggesting a facility dismisses the caregiver's wishes.
The nurse is talking with the parents of a 7-year-old client with newly diagnosed type 1 diabetes mellitus. Which of the following statements by the parents would indicate effective coping?
- A. Our child may not be able to participate in any sporting activities'
- B. Our whole family is willing to make sacrifices for our child's health.'
- C. We will make separate meals for our child to accommodate any dietary needs.'
- D. We are working to manage this condition so that our child can have an independent life.'
Correct Answer: D
Rationale: Aiming for the child's independence in managing diabetes indicates effective coping by focusing on empowerment. Assuming no sports or separate meals is overly restrictive, and vague sacrifices lack specificity.
An adult woman who has multiple sclerosis (MS) asks the nurse why she developed multiple sclerosis. What information should the nurse include when responding?
- A. MS usually follows a streptococcal infection.
- B. MS is an autoimmune condition.
- C. MS occurs more often among persons who have had chickenpox.
- D. MS may be related to mosquito bites.
Correct Answer: B
Rationale: Multiple sclerosis is an autoimmune disorder where the immune system attacks myelin in the central nervous system, unlike infections or mosquito bites.
The nurse notes all of the following. Which should be attended to first?
- A. A blind client is calling out stating that she cannot find the call bell.
- B. There is a water spill on the floor near the bed of an elderly client who ambulates regularly.
- C. A postoperative client is asking for pain medication.
- D. A diabetic client is asking for a glass of water.
Correct Answer: B
Rationale: A water spill near an ambulatory elderly client's bed poses an immediate fall risk, requiring prompt attention to ensure safety. Call bell access, pain, or water requests are less critical.