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After delivery, a newborn undergoes an Apgar assessment. What does this scoring system evaluate?
- A. heart rate, respiratory effort, color, muscle tone, reflex irritability
- B. heart rate, bleeding, cyanosis, edema
- C. bleeding, reflex, edema
- D. respiratory effort, heart rate, seizures
Correct Answer: B
Rationale: The Apgar scoring system, developed by Virginia Apgar, an anesthesiologist, evaluates newborns based on five criteria: heart rate, respiratory effort, color, muscle tone, and reflex irritability. These parameters provide a quick and simple assessment of a newborn's overall condition and the need for immediate medical attention. Choices B, C, and D are incorrect as they do not encompass the essential elements evaluated by the Apgar scoring system.
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A client with which of the following conditions is at risk for developing a high ammonia level?
- A. renal failure
- B. psoriasis
- C. lupus
- D. cirrhosis
Correct Answer: D
Rationale: A client with cirrhosis is at risk for developing a high ammonia level due to impaired liver function. The liver normally converts ammonia into urea for excretion. In cirrhosis, this process is compromised, leading to elevated ammonia levels in the blood. Renal failure, psoriasis, and lupus do not typically cause high ammonia levels. Renal failure affects kidney function, while psoriasis and lupus are autoimmune conditions that do not directly impact ammonia metabolism.
People living in poverty are most likely to obtain health care from:
- A. their primary care physician (family doctor)
- B. a neighborhood clinic
- C. specialists
- D. Emergency Departments or urgent care centers
Correct Answer: D
Rationale: People living in poverty often face barriers to accessing regular healthcare services, leading them to seek care in Emergency Departments or urgent care centers. These facilities are more accessible and do not require appointments or insurance, making them a common choice for individuals with limited resources. Neighborhood clinics, while a good option, may not always be available or affordable for those in poverty. Specialists provide specialized care but usually require a referral from a primary care provider, which individuals in poverty may not have consistent access to. Therefore, Emergency Departments or urgent care centers are the most likely sources of healthcare for people living in poverty.
Which of the following foods might a client with hypercholesterolemia need to decrease intake of?
- A. broiled catfish
- B. hamburgers
- C. wheat bread
- D. fresh apples
Correct Answer: B
Rationale: A client with hypercholesterolemia needs to decrease intake of foods that are high in cholesterol. Red meats like hamburgers are high in cholesterol, so their consumption should be reduced. Broiled catfish, wheat bread, and fresh apples are not high in cholesterol and do not need to be decreased in the client's diet. Therefore, the correct answer is hamburgers, as they are more likely to contribute to elevated cholesterol levels compared to the other options provided.
In an emergency situation, the nurse determines whether a client has an airway obstruction. Which of the following does the nurse assess?
- A. ability to speak
- B. ability to hear
- C. oxygen saturation
- D. adventitious breath sounds
Correct Answer: A
Rationale: In an emergency situation to assess for airway obstruction, the nurse should prioritize assessing the client's ability to speak. If a client can speak, it indicates that the airway is patent and not completely obstructed, allowing air to pass through the vocal cords for speech production. Choices B, C, and D are not the primary assessments for determining airway obstruction. Assessing the ability to hear is not directly related to an airway obstruction. While oxygen saturation and adventitious breath sounds are important in respiratory assessments, they are not the initial indicators of an airway obstruction. Oxygen saturation reflects the amount of oxygen in the blood, and adventitious breath sounds refer to abnormal lung sounds that may indicate conditions like pneumonia or bronchitis, but they do not specifically confirm airway patency.
Why is padding on a restraint helpful?
- A. To distribute pressure so that bony prominences do not receive pressure when a client pulls against the restraints.
- B. To help the client feel more secure.
- C. To keep infection and wounds at bay.
- D. To keep restraints in place.
Correct Answer: A
Rationale: Padding on a restraint helps distribute pressure to prevent bony prominences from bearing excessive pressure when a client pulls against the restraints. This is crucial to avoid tissue damage caused by ischemia. The correct answer focuses on the physiological benefit of padding in reducing pressure on vulnerable areas to prevent harm. Choice B is incorrect as the primary purpose of padding is not emotional comfort but preventing physical harm. Choice C is incorrect as while padding can indirectly help prevent infection and wounds by reducing pressure, its primary function is pressure distribution. Choice D is incorrect as the main purpose of padding is not to keep the restraints in place but to protect the client's skin and tissues from pressure-related injuries.