Nokea
A nine-month-old child with complaints of a fever of 102.2°F (39°C) and frequent vomiting.
The nurse would expect which of the following reflexes to still be present?
- A. Babinski's reflex.
- B. Moro's reflex.
- C. Tonic neck reflex.
- D. Grasp reflex.
Correct Answer: A
Rationale: Strategy: Think about growth and development. (1) correct-stroking outer sole of foot upward causes toes to hyperextend and fan and great toe to dorsiflex, disappears after one year of age (2) sudden jarring causes extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape, disappears after 3-4 months (3) when head is turned to side, arm and leg extend on that side, and opposite arm and leg flex, disappears by age 3-4 months (4) touching palms of hands or soles of feet causes flexion of hands and toes, palmar grasp disappears after 3 months of age, plantar grasp lessened by 8 months of age
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The nurse answers the psychiatric unit's desk phone. The caller identifies himself as the husband of a patient and inquires about her condition.
Which of the following responses by the nurse is MOST appropriate?
- A. I may not deny or confirm any patient's presence in this hospital.'
- B. Patients are not allowed to use this phone. Please call the patient's phone number directly.'
- C. I cannot give information over the phone. If you come in we can discuss her condition.'
- D. I will have to ask her if she wishes for me to give out that information.'
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) confidentiality prohibits a professional from discussing information about the patient (2) correct-psychiatric patient retains civil rights to communicate with outside world and have reasonable access to telephones (3) breaks confidentiality (4) patient able to speak for herself
An adult is being discharged from the emergency room with instructions to apply a cold pack to his sprained ankle. The client asks why it is necessary to use a cold pack. The nurse replies that the cold pack will do which of the following?
- A. Keep the sprain from becoming a fracture
- B. Prevent bruising and ecchymosis from occurring
- C. Keep the client from developing a fever
- D. Help reduce swelling and pain
Correct Answer: D
Rationale: Cold packs reduce swelling and pain by constricting blood vessels and numbing the area, aiding sprain recovery. They don't prevent fractures, bruising, or fever.
The nurse is caring for a client with a history of schizophrenia who is receiving haloperidol (Haldol) 5 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel stiff when I walk.
- B. I have a dry mouth.
- C. I feel sleepy in the afternoon.
- D. I have a headache sometimes.
Correct Answer: A
Rationale: Stiffness when walking suggests extrapyramidal symptoms (EPS), a serious side effect of haloperidol, requiring evaluation for possible dose adjustment or antiparkinsonian medication. Options B, C, and D are common, less urgent side effects: dry mouth, sedation, and headaches.
The nurse is caring for a client with a history of hyponatremia.
- A. Which intervention is most appropriate for a client with hyponatremia?
- B. Administer hypertonic saline slowly.
- C. Encourage a low-sodium diet.
- D. Restrict fluid intake.
- E. Administer a diuretic.
Correct Answer: A
Rationale: Administering hypertonic saline slowly corrects hyponatremia by raising serum sodium levels, preventing cerebral edema. Low-sodium diets worsen hyponatremia, fluid restriction is for hypervolemic cases, and diuretics are contraindicated.
Following a CT scan with contrast medium, the nurse should give attention to:
- A. Maintaining bed rest for 8 hours
- B. Forcing fluids
- C. Observing the puncture site for hemorrhage
- D. Administering pain medication
Correct Answer: B
Rationale: Forcing fluids promotes excretion of contrast medium, reducing risk of renal toxicity. Bed rest and hemorrhage monitoring are not typically required.