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What is the first action the nurse should take?
- A. Start an IV lines for fluids
- B. Get an ECG
- C. Place a Foley catheter
- D. Check for neurologic status
Correct Answer: D
Rationale: The first action the nurse should take is to check for neurologic status. This is essential in assessing the patient's level of consciousness, orientation, motor function, and pupil responses. It helps determine if the patient is experiencing neurological issues such as a stroke, which would require immediate medical attention. Checking neurologic status is a priority because it guides the nurse in identifying the next steps for the patient's care.
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Hemangiomas are the most common benign tumors of infancy, occurring more in full-term infants. Of the following, the most common risk factor of development of hemangioma is
- A. male infant
- B. female infant
- C. infant of diabetic mother
- D. infant delivered by cesarean section
Correct Answer: B
Rationale: Female infants are at higher risk for developing hemangiomas.
Which of the ff. is a symptom that the nurse would expect to find during assessment of a patient experiencing acute angle-closure glaucoma?
- A. Flashing lights
- B. Lens opacity
- C. Halos around lights A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET N
Correct Answer: C
Rationale: Halos around lights are a common symptom observed in patients experiencing acute angle-closure glaucoma. This occurs due to the increased intraocular pressure causing corneal edema, which leads to light scattering and the appearance of halos. Other symptoms may include severe eye pain, redness in the eye, decreased vision, and headache. It is important for the nurse to recognize these symptoms promptly as acute angle-closure glaucoma is a medical emergency that requires immediate treatment to prevent permanent vision loss.
The MOST common behavioral sleep disorder in a 4-month-old baby who needs to be rocked to sleep is
- A. early signs of ADHD
- B. primary restless legs syndrome
- C. sleep terrors
- D. sleep-onset association disorder
Correct Answer: D
Rationale: Sleep-onset association disorder involves reliance on specific conditions to fall asleep.
The MOST common behavioral sleep disorder in a 4-month-old baby who needs to be rocked to sleep is
- A. early signs of ADHD
- B. primary restless legs syndrome
- C. sleep terrors
- D. sleep-onset association disorder
Correct Answer: D
Rationale: Sleep-onset association disorder involves reliance on specific conditions to fall asleep.
An adolescent has been diagnosed with lactose maldigestion intolerance. The nurse teaches the adolescent about lactose maldigestion intolerance and notes the teen needs further teaching if which statement is made?
- A. "I will limit my milk consumption to one to two glasses a day."
- B. "I should drink the milk alone and not with other foods."
- C. "Hard cheese, cottage cheese, or yogurt can be substituted for milk."
- D. "I will take a calcium supplement daily."
Correct Answer: B
Rationale: This statement is incorrect because drinking milk alone without other foods is not necessary for someone with lactose maldigestion intolerance. Mixing milk with other foods or consuming dairy products alongside other foods can sometimes help to reduce symptoms. Therefore, the adolescent does not need further teaching if they make this statement. The other statements are all appropriate for managing lactose maldigestion intolerance.