Nokea
Which aspect should the nurse focus on when assessing a client for the vegetative signs of depression? Select all that apply.
- A. Weight
- B. Appetite
- C. Sleep patterns
- D. Suicidal ideations
- E. Psychomotor activity
- F. Rational decision making
Correct Answer: A,B,C,E
Rationale: The vegetative signs of depression are changes in physiological functioning that occur during depression. These include changes in appetite, weight, sleep patterns, and psychomotor activity. The remaining options represent psychological assessment categories.
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A client at 35 weeks of gestation reports a sudden discharge of fluid from the vagina. Based on the data provided, which condition should the nurse suspect?
- A. Miscarriage
- B. Preterm labor
- C. Intrauterine fetal demise
- D. Premature rupture of the membranes
Correct Answer: D
Rationale: Premature rupture of the membranes is usually manifested by a sudden discharge of fluid from the vagina before 37 weeks of gestation. Miscarriage is typically manifested by vaginal bleeding and abdominal pain. Preterm labor is typically manifested by uterine contractions, cramping, and pressure before 37 weeks of gestation. Intrauterine fetal demise is usually manifested by an absence of fetal movements and heartbeat.
The nurse is caring for a client diagnosed with acquired immunodeficiency syndrome (AIDS). Which sign/symptom indicates the presence of an opportunistic respiratory infection?
- A. Nausea and vomiting
- B. Fever and exertional dyspnea
- C. An arterial blood gas pH of 7.40
- D. A respiratory rate of 20 breaths per minute
Correct Answer: B
Rationale: Fever and exertional dyspnea are signs of Pneumocystis jiroveci pneumonia, which is a common, life-threatening opportunistic infection that afflicts those with AIDS. Option 1 is not associated with respiratory infection. Options 3 and 4 are normal findings.
The nurse performs an Allen's test before blood is drawn from the radial artery for an arterial blood gas (ABG) assessment. This intervention is done to determine the collateral circulatory adequacy of which arterial vessel?
- A. Ulnar
- B. Carotid
- C. Brachial
- D. Femoral
Correct Answer: A
Rationale: Before radial puncture for obtaining an arterial specimen for ABGs, Allen's test is performed to determine adequate ulnar circulation. Failure to assess collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Allen's test does not determine the adequacy of carotid, brachial, or femoral circulation.
The nurse assessing the level of consciousness of a child with a head injury documents that the child is obtunded. On the basis of this documentation, which observation did the nurse note?
- A. The child is unable to think clearly and rapidly.
- B. The child is unable to recognize place or person.
- C. The child always requires considerable stimulation for arousal.
- D. The child has limited interaction with the environment unless aroused.
Correct Answer: D
Rationale: If the child is obtunded, the child sleeps unless aroused and, when aroused, has limited interaction with the environment. The remaining options describe confusion, disorientation, and stupor.
The nurse caring for a child diagnosed with rubeola (measles) notes that the primary health care provider has documented the presence of Koplik's spots. On the basis of this documentation, which observation is expected?
- A. Pinpoint petechiae noted on both legs
- B. Whitish vesicles located across the chest
- C. Petechiae spots that are reddish and pinpoint on the soft palate
- D. Small, blue-white spots with a red base found on the buccal mucosa
Correct Answer: D
Rationale: In rubeola (measles), Koplik's spots appear approximately 2 days before the appearance of the rash. These are small, blue-white spots with a red base that are found on the buccal mucosa. The spots last approximately 3 days, after which time they slough off. Based on this information, the remaining options are all incorrect.