Nursing Elites

1. A newborn baby exhibits a reflex that includes hand opening, abducted, and extended extremities following a jarring motion. Which of the following correctly identifies the reflex?

• A. ATNR reflex
• B. Startle reflex
• C. Grasping reflex
• D. Moro reflex

Correct answer: D

Rationale: The Moro reflex, also known as the startle reflex, is the correct answer. This reflex is characterized by the baby's response to a sudden head movement or loud noise, causing them to open their hands, extend their arms, and then bring them back towards their body. The characteristics mentioned in the question - hand opening, abducted, and extended extremities following a jarring motion - align with the Moro reflex. The asymmetrical tonic neck reflex (ATNR) involves the head turning to one side with extension of the same side's arm and leg, not the described characteristics. The grasping reflex involves the baby's response to touch on the palm, causing them to grasp an object. While the Moro reflex is often referred to as the startle reflex due to its response to sudden stimuli, the specific characteristics described in the question match the Moro reflex.

2. Which client should the nurse see first?

• A. Recurring crushing chest pain
• B. Needing an IV for surgery in 5 minutes
• C. Needing PCA morphine for pain control post-hysterectomy
• D. Waiting to get back to bed after sitting in a chair for 30 minutes

Correct answer: A

Rationale: The client presenting with recurring crushing chest pain should be seen first as this symptom could indicate a myocardial infarction (MI), which is a life-threatening condition requiring immediate attention. Assessing and managing potential cardiac issues take priority over other concerns like needing an IV for surgery, pain control post-hysterectomy, or assistance with mobility. While all clients require care, addressing the chest pain promptly is crucial to ensure the client's safety and well-being.

3. A client with a history of peptic ulcer disease arrives in the emergency department complaining of weakness and states that he vomited 'a lot of dark coffee-looking stomach contents.' The client is cool and moist to the touch. BP 90/50, HR 110, RR 20, T 98. Of the following physician orders, which will the nurse perform first?

• A. Initiate oxygen at 2 liters/nasal cannula.
• B. Start an IV of NS at 150 ml/hr
• C. Insert NG tube to low suction
• D. Attach the client to the ECG monitor

Correct answer: A

Rationale: The correct answer is to initiate oxygen at 2 liters/nasal cannula. The client is presenting signs of shock with hypotension, tachycardia, and cool, moist skin, which indicate poor tissue perfusion. Oxygen should be administered first to improve tissue oxygenation. While all interventions are important, oxygenation takes priority in the ABCs of emergency care. Starting an IV of NS, inserting an NG tube, and attaching the client to the ECG monitor are necessary interventions but should follow the priority of oxygen administration in this scenario.

4. Which system is primarily affected by tuberculosis (Mycobacterium)?

• A. stomach (GI)
• B. heart (cardiac)
• C. lungs (respiratory)
• D. skin (integumentary)

Correct answer: C

Rationale: Tuberculosis, caused by Mycobacterium tuberculosis, primarily affects the respiratory system. This aerobic bacillus thrives in highly oxygenated body sites, such as the lungs, growing ends of bones, and the brain. The bacillus is airborne, making the lungs a common site for infection. Choices A, B, and D are incorrect as tuberculosis predominantly impacts the respiratory system and rarely involves the stomach, heart, or skin.

5. Is head lag expected to be resolved by 4 months of age? Continuing head lag at 6 months of age may indicate?

• A. Dizziness and orthostatic hypotension.
• B. Nausea, vomiting, diarrhea, or constipation, and stomach cramps.
• C. Drowsiness, lethargy, and fatigue.
• D. Neuropathy and tingling in the extremities.

Correct answer: B

Rationale: Head lag is a developmental milestone that should be resolved by 4 months of age. Continuing head lag at 6 months of age may indicate potential developmental delays or muscle weakness. The correct answer, 'Nausea, vomiting, diarrhea, or constipation, and stomach cramps,' reflects symptoms that could be associated with developmental delays or underlying health conditions. Dizziness and orthostatic hypotension (Choice A) are unlikely to be directly related to head lag. Choices C and D present symptoms that are unrelated to the issue of continued head lag at 6 months of age.

Similar Questions