Nokea
The nurse is assessing the reflexes of a full-term newborn infant. Which of the following is true regarding newborn reflexes?
- A. The Babinski reflex disappears after 1 year of age.
- B. Complete fencing response disappears by 2 months.
- C. The stepping or 'walking' reflex is present until 3-4 months.
- D. The Moro reflex is present at birth and disappears by 6 months.
Correct Answer: D
Rationale: The Moro reflex, present at birth, typically disappears by 6 months. Babinski persists until ~2 years, fencing (tonic neck) until 4-6 months, and stepping until 1-2 months.
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The nurse recognizes all of the following as type IV hypersensitivity reactions EXCEPT
- A. allergic contact dermatitis.
- B. Crohn's disease.
- C. graft versus host disease.
- D. penicillin allergy.
Correct Answer: D
Rationale: Type IV hypersensitivity is cell-mediated (e.g., contact dermatitis, Crohn’s, GVHD). Penicillin allergy is typically type I (IgE-mediated).
A client must take oral potassium supplements every day. The nurse explains to the client that the potassium supplements
- A. need to be stored in the refrigerator.
- B. should only be taken in the evening before bed.
- C. should be diluted in a glass of cold water or juice.
- D. need to be taken on an empty stomach.
Correct Answer: C
Rationale: Oral potassium supplements should be diluted in water or juice to reduce gastric irritation and improve absorption.
A student nurse is developing a care plan for a 23-year-old woman with Meniere's disease. Which of the following would NOT be an expected intervention?
- A. administer narcotic pain medication PRN as ordered
- B. refer client to dietician to plan meals with reduced sodium levels
- C. assist client out of bed to shower and to toilet
- D. encourage client to eat several, similarly sized meals throughout the day
Correct Answer: A
Rationale: Meniere’s disease causes vertigo and hearing loss, not typically requiring narcotic pain medication. Low-sodium diets, assistance with mobility, and balanced meals help manage symptoms.
The nurse is caring for a client with suspected AIDS dementia complex. The first sign of dementia in the client with AIDS is:
- A. Changes in gait
- B. Loss of concentration
- C. Problems with speech
- D. Seizures
Correct Answer: B
Rationale: Loss of concentration is an early cognitive change in AIDS dementia complex.
The nurse is caring for a client with full thickness burns to the lower half of the torso and lower extremities. During the emergent phase of injury, the primary nursing diagnosis would focus on:
- A. Ineffective airway clearance
- B. Impaired gas exchange
- C. Fluid volume deficit
- D. Pain
Correct Answer: C
Rationale: In the emergent phase of burns, fluid volume deficit is the priority due to massive fluid loss from damaged skin, risking hypovolemic shock.