Nokea
The nurse is responsible for performing a neonatal assessment on a fullterm infant. At 1 minute, the nurse could expect to find:
- A. An apical pulse of 100
- B. An absence of tonus
- C. Cyanosis of the feet and hands
- D. Jaundice of the skin and sclera
Correct Answer: C
Rationale: Acrocyanosis (cyanosis of hands and feet) is normal in newborns at 1 minute due to immature circulation.
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A pediatric nurse would be concerned by which of the following sets of vital signs?
- A. newborn: BP 70/50, RR 47, HR 135
- B. 12-month-old: BP 65/55, RR 50, HR 130
- C. 10-year-old: BP 110/70, RR 16, HR 89
- D. 13-year-old: BP 120/82, RR 15, HR 80
Correct Answer: B
Rationale: 12-month-old vitals (BP 65/55, RR 50, HR 130) show low BP (normal ~90/50) and high RR (normal 20-30), suggesting distress. Other options are age-appropriate.
The nurse is reviewing the lab results of four clients. Which finding should be reported to the physician?
- A. A client with chronic renal failure with a serum creatinine of 5.6 mg/dL
- B. A client with rheumatic fever with a positive C reactive protein
- C. A client with gastroenteritis with a hematocrit of 52%
- D. A client with epilepsy with a white cell count of 3,800 mm³
Correct Answer: C
Rationale: A hematocrit of 52% in gastroenteritis suggests dehydration, which requires immediate reporting.
During the nurse's assessment of a client who has been diagnosed with anorexia nervosa, the nurse evaluates certain characteristics that accompany an intense fear of gaining weight. What characteristics are most applicable? Select all that apply.
- A. fatigue
- B. excessive exercise regime
- C. normal weight
- D. high blood pressure
Correct Answer: A,B
Rationale: Fatigue and excessive exercise are common in anorexia nervosa due to malnutrition and compulsive behaviors. Normal weight or high blood pressure are less typical.
The nurse is preparing a client with gastroesophageal reflux disease (GERD) for discharge. The nurse should tell the client to:
- A. Eat a small snack before bedtime
- B. Sleep on his right side
- C. Avoid carbonated beverages
- D. Increase his intake of citrus fruits
Correct Answer: C
Rationale: Carbonated beverages can increase stomach pressure and worsen GERD symptoms by promoting acid reflux.
The clinic nurse is seeing a client who suffers from caregiver strain due to caring for her elderly parents who have dementia and live with her. Which action by the nurse during the assessment is most important?
- A. ask the client about her support systems
- B. ask the client what she does for relaxation
- C. ask if her parents' insurance covers adult day care for them
- D. offer to give her a list of nursing homes to care for her parents
Correct Answer: A
Rationale: Assessing support systems identifies resources to alleviate caregiver strain, guiding interventions to reduce stress.