Nokea
Which skin assessment in a newborn indicates a need for follow-up?
- A. Miliaria rubra
- B. Erythema toxicum
- C. Mongolian spots
- D. Jaundice at birth
Correct Answer: D
Rationale: Jaundice at birth is abnormal and may indicate hemolytic disease liver dysfunction or other serious conditions requiring immediate follow-up. Miliaria rubra erythema toxicum and Mongolian spots are benign and common in newborns.
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A client has developed diabetes insipidus after removal of a pituitary tumor. Which finding would the nurse expect?
- A. Polyuria
- B. Hypertension
- C. Polyphagia
- D. Hyperkalemia
Correct Answer: A
Rationale: Diabetes insipidus causes polyuria due to deficient antidiuretic hormone, leading to excessive water loss. Hypertension (B), polyphagia (C), and hyperkalemia (D) are not typical.
The nurse is caring for a client with a history of Addison’s disease. Which finding indicates a potential adrenal crisis?
- A. Blood pressure of 90/60 mmHg
- B. Weight gain of 2 pounds
- C. Serum sodium of 140 mEq/L
- D. Heart rate of 80 beats per minute
Correct Answer: A
Rationale: Adrenal crisis in Addison’s disease causes hypotension (e.g., 90/60 mmHg) due to cortisol and aldosterone deficiency, leading to shock. Weight gain, normal sodium, and normal heart rate are not indicative.
A client is admitted with disseminated herpes zoster (shingles). According to the Centers for Disease Control Guidelines for Infection Control:
- A. Airborne precautions will be needed.
- B. No special precautions will be needed.
- C. Only contact precautions will be needed.
- D. Droplet precautions will be needed.
Correct Answer: A
Rationale: Disseminated herpes zoster requires airborne precautions because the varicella-zoster virus can spread through respiratory droplets in immunocompromised patients.
What information should the nurse give a new mother regarding the introduction of solid foods for her infant?
- A. Solid foods should not be given until the extrusion reflex disappears at 8-10 months of age.
- B. Solid foods should be introduced one at a time, with 4- to 7-day intervals.
- C. Solid foods can be mixed in a bottle or infant feeder, to make feeding easier.
- D. Solid foods should begin with fruits and vegetables.
Correct Answer: B
Rationale: Introducing solid foods one at a time with 4-7 day intervals allows identification of allergies. The extrusion reflex fades by 4-6 months, and mixing in bottles or starting with fruits is not recommended.
The physician has prescribed Synthroid (levothyroxine) for a client with myxedema. Which statement indicates that the client understands the nurse's teaching regarding the medication?
- A. I will take the medication each morning after breakfast.
- B. I will check my heart rate before taking the medication.
- C. I will report visual disturbances to my doctor.
- D. I will stop the medication if I develop gastric upset.
Correct Answer: C
Rationale: Reporting visual disturbances is important, as levothyroxine can rarely cause visual changes, indicating a need for medical evaluation. It should be taken before breakfast, not stopped for gastric upset.