Nokea
Which withdrawal symptom is the nurse most likely to note while observing the newborn of a mother who used heroin during pregnancy?
- A. Tremors
- B. Lethargy
- C. Poor feeding
- D. High-pitched cry
Correct Answer: A,C,D
Rationale: Tremors, poor feeding, and high-pitched cry are common symptoms of neonatal opioid withdrawal.
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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.
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.
Which of the following are behavioral effects of anabolic steroids?
- A. Aggression and rage
- B. Confusion and doubt
- C. Anxiety and depression
- D. Paranoia and suicidal ideation
Correct Answer: A
Rationale: Aggression and rage are well-documented effects of steroid use.
If the adolescent is typical of others who have grown up in an alcoholic family, the nurse would expect to assess for problems in which area?
- A. Low self-esteem
- B. Managing stress
- C. Long-term learning
- D. Fear of authority
Correct Answer: A
Rationale: Low self-esteem is common in children of alcoholics due to unpredictable environments.
On the basis of the nurse's knowledge of autistic behavior, which nursing diagnosis is most likely to be a priority in the team conference?
- A. Ineffective health maintenance
- B. Chronic low self-esteem
- C. Risk for activity intolerance
- D. Risk for self-directed violence
Correct Answer: D
Rationale: Self-directed violence is a priority due to potential self-injurious behaviors.