Nokea
The nurse is caring for clients on the neurology unit. What would be the MOST appropriate action for the nurse to take after noting that a client suddenly developed a fixed and dilated pupil?
- A. Reassess in five minutes.
- B. Check the client’s visual acuity.
- C. Lower the head of the client’s bed.
- D. Contact the physician.
Correct Answer: D
Rationale: implementation, fixed and dilated pupil represents a neurological emergency
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The nurse is caring for a newborn who is on strict intake and output. The used diaper weighs $73.5 \mathrm{gm}$. The diaper's dry weight was $62 \mathrm{gm}$. The newborn's urine output is:
- A. 10 ml
- B. 11.5 ml
- C. 10 gm
- D. 12 gm
Correct Answer: B
Rationale: Urine output is calculated by subtracting dry diaper weight from wet diaper weight: 73.5 gm - 62 gm = 11.5 ml (1 gm = 1 ml for urine).
A infant weighs 7 pounds at birth. The expected weight by 1 year should be:
- A. 10 pounds
- B. 12 pounds
- C. 18 pounds
- D. 21 pounds
Correct Answer: D
Rationale: Infants typically triple their birth weight by 1 year, so a 7-pound infant should weigh approximately 21 pounds.
The nurse is making assignments for the day. The staff consists of an RN, a novice RN, an LPN, and a nursing assistant. Which client should be assigned to the RN?
- A. A client with peptic ulcer disease
- B. A client with skeletal traction for a fractured femur
- C. A client with an abdominal cholecystectomy
- D. A client with an esophageal tamponade
Correct Answer: D
Rationale: The client with an esophageal tamponade requires complex monitoring and intervention, best suited for an experienced RN.
A client's wife states that her elderly husband has begun to slightly slur his words and drop word endings, he has become increasingly withdrawn socially, and he is irritable, accusing her of talking behind his back and whispering at him. The nurse suspects that the client should be initially evaluated for which of the following?
- A. Depression.
- B. Alzheimer's disease.
- C. Hearing loss.
- D. Stroke.
Correct Answer: C
Rationale: Slurred speech, social withdrawal, and irritability with accusations of whispering suggest hearing loss (C), which can cause communication difficulties and paranoia. Depression (A), Alzheimer's (B), and stroke (D) are less likely to present with this specific combination.
A 32-year-old woman comes into the clinic for a well-woman exam and asks for information on an intrauterine device (IUD) for contraception. The nurse should explain that all of the following are potential risks EXCEPT
- A. stroke.
- B. pelvic infections.
- C. abnormal menstrual bleeding.
- D. ectopic pregnancy.
Correct Answer: A
Rationale: IUD risks include pelvic infections, abnormal bleeding, and ectopic pregnancy. Stroke is not a recognized risk associated with IUD use.