Nokea
The nurse is caring for a newborn. Which of the following signs would indicate neonatal abstinence syndrome? Select all that apply.
- A. Irritability and restlessness
- B. Meconium ileus and floppy muscle tone
- C. Microcephaly and cleft palate
- D. Nasal congestion and frequent sneezing
- E. Poor feeding and loose stools
Correct Answer: A,D,E
Rationale: Neonatal abstinence syndrome includes irritability , nasal congestion and sneezing , and poor feeding with loose stools due to withdrawal. Meconium ileus and hypotonia suggest cystic fibrosis, and microcephaly and cleft palate are congenital anomalies.
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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 collecting data on a client who has arrived at the clinic for pregnancy confirmation and prenatal evaluation. Which of the following findings indicate diagnostic evidence (positive signs) of pregnancy? Select all that apply.
- A. Cervical softening upon examination
- B. Fetal heart tones detected by Doppler device
- C. Positive serum human chorionic gonadotropin test
- D. Report of fetal movement felt by client
- E. Visualization of fetus via ultrasound
Correct Answer: B,E
Rationale: Positive signs of pregnancy are objective, provider-verified findings: fetal heart tones by Doppler and ultrasound visualization . Cervical softening and hCG test are probable signs, and fetal movement is subjective.
The nurse in the emergency department is caring for a client who was involved in a motor vehicle collision. Which of the following diagnostic test results would best determine the client's oxygenation and ventilation status?
- A. peak expiratory flow rate reading
- B. arterial blood gas analysis
- C. pulse oximetry reading
- D. CT scan of the chest
Correct Answer: B
Rationale: Arterial blood gas provides the most accurate assessment of oxygenation (PaO2) and ventilation (PaCO2) post-collision. Peak flow assesses asthma, pulse oximetry measures oxygen saturation only, and CT evaluates structure.
The nurse is discussing mammogram screening with a family. No one in the family has had a mammogram. The mother is 52, there are four daughters, ages 10, 15, 21, and 34, and the grandmother is 75. Which of the following women should receive a mammogram? Select all that apply.
- A. The 10-year old daughter
- B. The 15-year old daughter
- C. The 21-year old daughter
- D. The 34-year old daughter
- E. The 52-year old mother
- F. The 75-year-old grandmother
Correct Answer: D,E,F
Rationale: Women aged 40 and older, or earlier with risk factors, should have mammograms. The 34-year-old, 52-year-old, and 75-year-old women meet screening age criteria.
A 72-year-old woman is being treated for pneumonia. Physician's orders include an antibiotic, oxygen PRN for O2 saturation less than 90, and pulse oximetry every 4 hours. The nurse obtains a pulse oximetry reading of 82% on room air. What is the best action for the nurse to take?
- A. Report the finding to the physician
- B. Report the finding to the registered nurse to get instructions
- C. Start supplemental oxygen
- D. Start oxygen and repeat the pulse oximetry in 20 minutes
Correct Answer: C
Rationale: An O2 saturation of 82% requires immediate supplemental oxygen per orders to correct hypoxia, the priority action.