Nokea
The nurse is assessing a newborn in the well-baby nursery. Which finding should alert the nurse to the possibility of a cardiac anomaly?
- A. Diminished femoral pulses
- B. Harlequin's sign
- C. Circumoral pallor
- D. Acrocyanosis
Correct Answer: A
Rationale: Diminished femoral pulses suggest coarctation of the aorta, a cardiac anomaly, requiring further evaluation.
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The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention?
- A. Suggest that the client take warm showers two times per day
- B. Add baby oil to the client's bath water
- C. Apply powder to the client's skin
- D. Suggest a hot-water rinse after bathing
Correct Answer: B
Rationale: Adding baby oil to bath water helps moisturize the skin and alleviate pruritis caused by hepatitis, as it soothes dry, itchy skin without causing irritation.
A client diagnosed with Alzheimer's disease initiates the same conversation repeatedly, becomes aggressive when stressed, needs reminders to perform ADLs, and is easily lost in his neighborhood. This client is likely in what stage of Alzheimer's disease?
- A. pre-Alzheimer's
- B. early/mild
- C. moderate
- D. late to severe
Correct Answer: C
Rationale: Moderate Alzheimer's involves repetitive behaviors, aggression, ADL dependence, and disorientation, as described, indicating significant cognitive decline.
The RN is planning client assignments. Which is the least appropriate task for the nursing assistant?
- A. Assisting a COPD client admitted 2 days ago to get up in the chair
- B. Feeding a client with bronchitis who is paralyzed on the right side
- C. Accompanying a discharged emphysema client to the transportation area
- D. Assessing an emphysema client complaining of difficulty breathing
Correct Answer: D
Rationale: Assessment of breathing difficulty requires RN expertise to evaluate and intervene, making it inappropriate for a nursing assistant.
The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is:
- A. Body image disturbance related to swelling of neck
- B. Anxiety-related changes in body image
- C. Altered nutrition, less than body requirements, related to difficulty in swallowing
- D. Risk for ineffective airway clearance related to pressure on the trachea
Correct Answer: D
Rationale: A goiter can compress the trachea, posing a risk for airway obstruction, making ineffective airway clearance the priority nursing diagnosis.
A client with cirrhosis has developed signs of heptorenal syndrome. Which diet is most appropriate for the client at this time?
- A. High protein, moderate sodium
- B. High carbohydrate, moderate sodium
- C. Low protein, low sodium
- D. Low carbohydrate, high protein
Correct Answer: C
Rationale: Low protein and low sodium diets reduce the burden on the liver and kidneys in hepatorenal syndrome.