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1. A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, 'I don't understand why my child is so upset. I've never seen my child act this way around others before.' Which of the following statements should the nurse make?
- A. This is a normal, expected reaction for a child of this age.
- B. This is a response to an overstimulating environment.
- C. This is a common reaction to an overexposure to caregivers.
- D. This is a typical reaction for a child who is sick.
Correct answer: A
Rationale: The correct answer is 'This is a normal, expected reaction for a child of this age.' Separation anxiety typically peaks around 8-10 months of age, leading to distress when separated from caregivers. Choice B is incorrect because the infant's behavior is more likely due to separation anxiety rather than overstimulation. Choice C is incorrect as the infant's behavior is not related to overexposure to caregivers but rather a natural developmental stage. Choice D is incorrect as the infant's behavior is not indicative of illness but rather a normal emotional response.
2. While the client has a pulse oximeter on his fingertip, you notice that sunlight is shining on the area where the oximeter is. Your action will be to:
- A. Set and turn on the alarm of the oximeter
- B. Do nothing since there is no identified problem
- C. Cover the fingertip sensor with a towel or bedsheet
- D. Change the location of the sensor every four hours
Correct answer: B
Rationale: In this scenario, the correct action is to do nothing since there is no identified problem with the sunlight shining on the area where the oximeter is placed. The functionality of the oximeter is not affected by sunlight, so covering it or changing its location unnecessarily could disrupt the monitoring process. Setting the alarm or changing the sensor location every four hours is not indicated in this situation and may lead to unnecessary interventions. It's essential to assess the situation carefully and intervene only when necessary, ensuring that care provided is appropriate and effective.
3. High blood pressure is defined as systolic and diastolic measurements greater than or equal to:
- A. 140 mm Hg and 90 mm Hg, respectively
- B. 150 mm Hg and 80 mm Hg, respectively
- C. 160 mm Hg and 110 mm Hg, respectively
- D. 180 mm Hg and 120 mm Hg, respectively
Correct answer: A
Rationale: High blood pressure, or hypertension, is typically defined as having a systolic pressure of 140 mm Hg or higher and/or a diastolic pressure of 90 mm Hg or higher. Therefore, the correct answer is A. Choice B is incorrect because it suggests a higher systolic measurement than the standard definition. Choice C is incorrect as it provides an even higher systolic measurement and a much higher diastolic measurement. Choice D is also incorrect as it suggests extremely elevated blood pressure values, well above the typical definition of hypertension.
4. Which of the following best describes Primary Nursing?
- A. Assigning a nurse to lead a team of registered nurses in the care of a patient from admission to discharge
- B. Assigning a nurse to perform administrative tasks in a healthcare setting
- C. Assigning a nurse to provide medical treatment without supervision
- D. Assigning a nurse to be the main caregiver responsible for coordinating all aspects of care for a group of patients
Correct answer: A
Rationale: Primary Nursing involves assigning a dedicated nurse to lead a team of registered nurses in the care of a patient from admission to discharge. This approach ensures continuity and personalized care. Choices B and C are incorrect as they do not accurately describe Primary Nursing. Choice D is incorrect as it refers to a different care delivery model.
5. Which factor contributes to the development of bone diseases in patients with Chronic Kidney Disease (CKD) due to retention?
- A. Iron
- B. Sodium
- C. Potassium
- D. Phosphorus
Correct answer: D
Rationale: The correct answer is phosphorus. Retention of phosphorus in patients with Chronic Kidney Disease (CKD) contributes to the development of bone disorders, including osteodystrophy, because it disrupts the balance of calcium and phosphorus in the body. This imbalance leads to a variety of bone diseases. The other options - iron, sodium, and potassium - while important in the overall metabolic function, are not directly linked to the development of bone diseases in CKD patients due to retention.
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