Nokea
When performing a brief check of the client's mental status, which question is most appropriate for assessing the client's orientation?
- A. What is today's date?
- B. How did you get here?
- C. Where were you born?
- D. Who is currently the U.S. president?
Correct Answer: A
Rationale: Asking the date assesses orientation to time, a key component.
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When the gym owner asks the teenager if he would like a drug to help increase muscle mass, which factor will most likely influence a desire to accept?
- A. Several teammates are taking this drug.
- B. The team is having a winning season.
- C. His parents support his interest in football.
- D. He can afford to pay for a substantial supply.
Correct Answer: A
Rationale: Peer influence is a strong motivator for adolescents.
What information strongly suggests that the child's fractured femur is the result of physical abuse?
- A. The nurse notes evidence of other healed fractures.
- B. Only the mother witnessed the injury.
- C. The child is not fully immunized yet.
- D. The child is underweight for height.
Correct Answer: A
Rationale: Multiple healed fractures suggest a pattern of abuse.
Which assessment findings are most characteristic of a 10-month-old infant with the diagnosis of failure to thrive?
- A. The infant cries vigorously when handled.
- B. The infant has a delay in developmental milestones.
- C. The infant appears pale and lethargic.
- D. The infant's sucking and grasp reflexes
- E. The infant has delayed understanding of speech.
Correct Answer: B,C,E
Rationale: Delayed milestones, pallor, lethargy, and speech delays are hallmark signs of failure to thrive.
When caring for a newborn experiencing opioid withdrawal, the nurse frequently puts the baby in the crib when crying.
- A. Reduce environmental stimuli.
- B. Touch the newborn frequently.
- C. Stroke the newborn's skin gently.
- D. Leave the newborn unwrapped.
Correct Answer: A
Rationale: Reducing stimuli helps calm the newborn and manage withdrawal symptoms.
On the basis of the principles of crisis intervention, when is the best time for the nurse to offer assistance to those most affected by this incident?
- A. After the funeral
- B. Within 6 months
- C. Immediately
- D. Six weeks later
Correct Answer: C
Rationale: Immediate intervention addresses acute distress and prevents long-term issues.