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Which information reported by the parents indicates a high risk for the presence of a brain tumor?
- A. The child vomits when first getting out of bed.
- B. The child frequently complains of nausea.
- C. The child forgets where homework is placed.
- D. The child's head tilts toward the side when sleeping.
Correct Answer: A
Rationale: Morning vomiting is a classic sign of increased intracranial pressure from a brain tumor, as pressure is highest after lying flat overnight, making it a high-risk indicator.
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Which finding documented by the nurse is most indicative of the presence of a Curling's ulcer in the burned child?
- A. Absence of bowel sounds
- B. A positive hemoccult test
- C. An elevated hematocrit
- D. A distended abdomen
Correct Answer: B
Rationale: A positive hemoccult test indicates gastrointestinal bleeding, characteristic of a Curling's ulcer, a stress ulcer common in burn patients due to physiological stress and reduced mucosal protection.
Which medication instruction provided by the nurse is most accurate?
- A. Taking your acyclovir as prescribed will prevent the recurrence of lesions.
- B. Your sex partners also need to be treated for 10 days with oral acyclovir.
- C. Use a glove to apply topical acyclovir.
- D. Take the oral acyclovir even when the disease is in remission.
Correct Answer: C
Rationale: Using a glove to apply topical acyclovir prevents self-contamination and virus spread, making it an accurate and safe instruction.
The nurse is completing the 1-minute Apgar assessment on the full-term newborn. The newborn’s HR is 80 bpm. What should the nurse do next?
- A. Assign a 2 for the Apgar score that pertains to the heart rate.
- B. Suction the excess secretions from the newborn’s oral cavity.
- C. Wrap in warm blankets and place on the mother’s abdomen.
- D. Begin immediate positive pressure ventilation on the newborn.
Correct Answer: D
Rationale: A newborn HR of less than 100 bpm scores as a 1 on the HR criterion and indicates a need to begin positive pressure ventilation by bag mask or Neopuff® ventilation. A score of 2 requires HR above 100 bpm. Suctioning is not indicated and wrapping is done after assessment.
A 30 years old G3P2 at 28 weeks of gestation presents with severe pain in the right flank radiating to her groin. She also complaints of rigors and chills. Urine analysis reveals numerous pus cells. The most likely diagnosis is:
- A. Appendicitis.
- B. Pyelonephritis.
- C. Round ligament torsion.
- D. Meckel's diverticulum.
- E. Torsion of ovarian cyst.
Correct Answer: B
Rationale: Pyelonephritis a urinary tract infection affecting the kidneys presents with flank pain fever,chills,and pus cells in urine,as described. Appendicitis typically involves right lower quadrant pain and other options lack urinary findings or are less likely in pregnancy.
The nurse receives a laboratory report result showing that the blood glucose is 48 mg/dL for a full-term newborn. Which action should be taken by the nurse?
- A. Have the mother breastfeed her newborn now.
- B. Immediately feed the infant water with 10% dextrose.
- C. Report the results immediately to the health care provider.
- D. Document the information in the newborn’s medical record.
Correct Answer: D
Rationale: Normal blood sugar values for a full-term newborn are 45–65 mg/dL. A value of 48 mg/dL is normal so the only action required is documentation. Feeding or reporting is unnecessary.