Nokea
The nurse measures the head and chest circumferences of a 20 month-old infant. After comparing the measurements, the nurse finds that they are approximately the same. What action should the nurse take?
- A. Notify the provider
- B. Palpate the anterior fontanel
- C. Examine the posterior fontanel
- D. Record these normal findings
Correct Answer: D
Rationale: Record these normal findings. Head and chest circumferences are typically equal by 1 to 2 years of age.
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The nurse is caring for four antepartum clients. Which client should the nurse see first?
- A. Client with hyperemesis gravidarum who is currently vomiting (9%)
- B. Client with molar pregnancy who has dark brown vaginal discharge (8%)
- C. Client with suspected ectopic pregnancy who has abdominal and shoulder pain (71%)
- D. Client with threatened miscarriage who says, 'I am a Jehovah's Witness.' (10%)
Correct Answer: C
Rationale: A suspected ectopic pregnancy is a medical emergency due to the risk of rupture and internal bleeding, which can be life-threatening. Abdominal and shoulder pain are hallmark symptoms, indicating possible referred pain from diaphragmatic irritation. This client requires immediate assessment and intervention, prioritizing over hyperemesis gravidarum (which, while serious, is less immediately life-threatening), molar pregnancy (which needs monitoring but is not an acute emergency), and threatened miscarriage (which requires evaluation but is less urgent without active bleeding or pain).
The nurse on the mental health unit is talking with a client with schizophrenia. Which of the following statements by the client would indicate that the client is experiencing a delusion of reference?
- A. Did you hear that voice? It told me to kill my parent.
- B. I need to get rid of the bugs that are crawling under my skin.
- C. The song on the radio is a message sent to me in secret code.
- D. I will not drink the tap water. The aliens are trying to poison me.
Correct Answer: C
Rationale: A delusion of reference involves believing neutral events or objects (e.g., a song on the radio) have personal significance or hidden messages (C). Auditory hallucinations (A) involve hearing voices, not reference. Tactile hallucinations (B) involve false sensations, and persecutory delusions (D) involve belief in harm without reference to neutral stimuli.
Laboratory results
WBC
5000-10,000/mm³
(5-10 × 10⁹/L) 1400/mm3
(1.4 × 109/L)
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)
Female: 12-16 g/dL
(120-160 g/L) 10 g/dL
(100 g/L)
Absolute neutrophil count
2500-8000/mm³
(2.5-8 × 10⁹/L) 500/mm3
(0.5 × 109/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 3.4 mEq/L
(3.4 mmol/L)
Platelets
150,000-400,000/mm³
(150-400 × 10⁹/L) 150,000/mm3
(150 × 109/L)
A client in the hospital is receiving chemotherapy. Based on today’s blood laboratory results, which of the following actions should the nurse take?
- A. Check for hematuria
- B. Check for peaked T waves
- C. Obtain prescription for epoetin alfa
- D. Place a face mask on the client
Correct Answer: D
Rationale: Chemotherapy often causes neutropenia, increasing infection risk. A face mask (D) protects the client. Hematuria (A), peaked T waves (B), and epoetin (C) address other issues not directly indicated.
A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective?
- A. I’m not worried about the device firing now because I know it won’t hurt.
- B. I will let my daughter fix my hair until my health care provider says I can do it.
- C. I will look into public transportation because I won’t be able to drive again.
- D. I will notify my travel agent that I can no longer travel by plane.
Correct Answer: B
Rationale: Avoiding hair-fixing (B) prevents arm movement that could dislodge leads, showing effective teaching. Device firing (A) can be uncomfortable, driving (C) is restricted temporarily, and air travel (D) is generally safe with precautions.
The nurse prepares a client for discharge following a vasectomy. The client asks, 'When can I have sexual intercourse with my wife without using a condom?' What is the best response by the nurse?
- A. Discontinue alternative birth control after at least 5 ejaculations.
- B. There is no need to use alternative birth control following today's procedure.
- C. Use alternative birth control for 6 months following today's procedure.
- D. Use alternative birth control until your physician confirms the absence of sperm in a semen analysis.
Correct Answer: D
Rationale: A vasectomy requires confirmation of azoospermia via semen analysis, typically after 6-12 weeks or 15-20 ejaculations, to ensure sterility. Alternative birth control (C) is needed until this confirmation. Immediate unprotected intercourse (A) risks pregnancy, and 6 months (B) is unnecessarily long.