Nursing Elites

1. A newborn presents with a pronounced cephalic hematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?

• A. Pain related to periosteal injury
• B. Impaired mobility related to bleeding
• C. Parental anxiety related to knowledge deficit
• D. Injury related to intracranial hemorrhage

Correct answer: C

Rationale: The correct nursing diagnosis to guide the plan of care for a newborn with a pronounced cephalic hematoma following a birth in the posterior position is 'Parental anxiety related to knowledge deficit.' This is appropriate because the parents may be worried about the appearance and potential complications of the cephalic hematoma. They may require education and reassurance from the nurse. Choices A, B, and D are incorrect because they do not address the emotional needs of the parents and the knowledge deficit they may have regarding the condition.

2. Iwa, two years old, was brought to the health center because of diarrhea for 4 days. Assessment revealed that Iwa has under-nutrition. Which of the following actions will you take?

• A. Advise the mother to give milk and juices between meals at home
• B. Give nutritious food available at home
• C. Refer to the hospital for proper management
• D. Provide mother with ORS solution and show her how to give the solution

Correct answer: A

Rationale: In the case of a child with under-nutrition and diarrhea, advising the mother to give milk and juices between meals at home is the appropriate action. This helps address the nutritional needs of the child while also providing hydration. Option B, giving nutritious food available at home, may not be sufficient in addressing immediate needs such as dehydration. Option C, referring to the hospital, may be necessary in severe cases but is not the first-line action. Option D, providing ORS solution, is important but does not directly address the under-nutrition concern.

3. A 6-month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents to

• A. Gently rub the skin with a cotton swab to relieve itching
• B. Place the favorite books and push-pull toys in the crib
• C. Check every few hours for the next day or 2 for swelling in the baby's feet
• D. Turn the baby with the abduction stabilizer bar every 2 hours

Correct answer: C

Rationale: The correct answer is to check every few hours for the next day or 2 for swelling in the baby's feet. Swelling in the baby's feet could indicate compromised circulation due to the cast, and frequent checks are necessary to ensure that there are no complications. Choices A, B, and D are incorrect because rubbing the skin with a cotton swab, placing favorite items in the crib, and turning the baby with the abduction stabilizer bar do not address the potential issue of compromised circulation and swelling in the baby's feet.

4. A person with no known illness whose daily routine consists of walking and following a healthy diet would be best characterized as engaging in which kind of activities?

• A. health balance
• B. disease prevention
• C. health promotion
• D. self-fulfillment

Correct answer: C

Rationale: The correct answer is C: health promotion. Health promotion activities involve maintaining a healthy lifestyle to prevent illness. In this scenario, the person is actively engaging in behaviors that promote their overall health and well-being, such as walking and following a healthy diet. Choice A, 'health balance,' is vague and does not specifically address the proactive nature of the person's actions. Choice B, 'disease prevention,' while related, focuses more on specific actions taken to prevent diseases rather than the broader concept of promoting overall health. Choice D, 'self-fulfillment,' does not directly relate to the activities described in the question.

5. A client with schizophrenia is receiving haloperidol (Haldol). The nurse should monitor the client for which of the following side effects?

• A. Tachycardia
• B. Hypotension
• C. Extrapyramidal symptoms
• D. Hyperglycemia

Correct answer: C

Rationale: The correct answer is C: Extrapyramidal symptoms. Haloperidol is a first-generation antipsychotic that can lead to extrapyramidal symptoms such as tardive dyskinesia and akathisia. These side effects are common with the use of typical antipsychotics. Choice A, Tachycardia, is not a common side effect of haloperidol. Choice B, Hypotension, is also not a typical side effect associated with haloperidol use. Choice D, Hyperglycemia, is not directly linked to haloperidol administration, as it is more commonly associated with other medications like atypical antipsychotics or certain medical conditions.

Similar Questions