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While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first?
- A. Ask the parents to allow the infant to lay on her stomach to promote muscle development
- B. Notify the physician because a developmental or neurological evaluation is indicated
- C. Document the findings as normal in the nurse's notes
- D. Explain to the parents that their child is likely to be mentally retarded
Correct Answer: B
Rationale: Persistent head lag at 6 months suggests developmental or neurological issues, warranting immediate physician referral for evaluation.
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Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care?
- A. I should put alcohol on my baby's cord 3-4 times a day.'
- B. I should put the baby's diaper on so that it covers the cord.'
- C. I should call the physician if the cord becomes dark.'
- D. I should wash my hands before and after I take care of the cord.'
Correct Answer: D
Rationale: Parents should be taught to wash their hands before and after providing cord care. This prevents transferring pathogens to and from the cord. Folding the diaper below the cord exposes the cord to air and allows for drying. It also prevents wet or soiled diapers from coming into contact with the cord. Current recommendations include cleaning the area around the cord 3-4 times a day with a cotton swab but do not include putting alcohol or other antimicrobials on the cord. It is normal for the cord to turn dark as it dries.
The nurse is admitting a client to the unit who says they would feel more reassured with an extra oxygen tank in their room because of a past incident when they were short of breath. Which of the following statements is the best response?
- A. I will make sure there is always an extra oxygen tank in your room.'
- B. I will ask the previous nurse if the extra tank was needed.'
- C. I will need to check if your insurance benefits would cover an additional oxygen tank.'
- D. The first priority is ensuring there are enough oxygen tanks for everyone who needs them. I am not sure we will be able to provide an extra on standby.'
Correct Answer: D
Rationale: The nurse should recognize the appropriate need for materials and equipment. The client's preference for extra equipment that other clients may need is not appropriate.
What is the primary theory that explains a family's concept of health and illness?
- A. Health Belief Model
- B. Education-School-Completing Factor
- C. Family Health Expert Factor
- D. Disconnected Family Factor
Correct Answer: A
Rationale: The Health Belief Model describes readiness factors; the perceived feelings of susceptibility and seriousness of the health problem (the threat); and positive motivation to maintain, regain, or attain wellness.
The nurse is caring for a client awaiting test results on a biopsy. The client is unconscious, and the physician informs the client's spouse that the biopsy came back positive for cancer. The spouse asks the nurse if they will not share this news with the client because they would prefer the client be unaware of the diagnosis. Which of the following responses is most appropriate?
- A. I will have a psychiatrist confirm that the news will cause negative effects, and if so, I will comply with your request.'
- B. For ethical reasons, I am unable to withhold this information from the client.'
- C. You will need to sign paperwork stating you are accepting the risk of not sharing this with the client.'
- D. You must have a durable power of attorney for health care advanced directive in place before I can consider this request.'
Correct Answer: B
Rationale: The ethical principle of veracity requires that the nurse is truthful with the client and does not withhold information even if it is requested by the family.
In what order should the LPN see the following clients? A. a 72-year-old client with pneumonia asking to order her dinner.,B. a 23-year-old client with left arm fracture after an MVA complaining of 6 out of 10 pain in his arm.,C. a 53-year-old client with lower leg swelling complaining of sudden onset headache and blurry vision. ,D. a 47-year-old client requesting more information regarding her surgery scheduled in three hours
- A. A) A, D, B, C
- B. B) C, B, D, A
- C. C) D, C, B, A
- D. D) B, C, A, D
Correct Answer: B
Rationale: Prioritizing client care is a critical skill to learn as a LPN. The 53-year-old is at highest risk for serious healthcare complications and should be seen first. The 23-year-old's pain should be addressed second, prior to answering questions about the 47-year-old's surgery. Finally, the LPN should address the needs of the 72-year-old client.