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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. Which of the following actions would be of highest priority with regards to the external shunt?
- A. Avoid taking blood pressure or blood sample from the arm with the shunt
- B. Instruct the patient not to exercise the arm with the shunt
- C. Heparinize the shunt daily
- D. Change the dressing of the shunt daily
Correct answer: C
Rationale: Heparinizing the shunt daily (choice C) is the highest priority action as it prevents the formation of blood clots that can occlude the shunt, leading to potential complications such as thrombosis. Avoiding taking blood pressure or blood samples from the arm with the shunt (choice A) is also important, but secondary to heparinizing the shunt. Similarly, instructing the patient not to exercise the arm with the shunt (choice B) can help prevent unnecessary strain on the shunt, but it is not as critical as preventing clot formation. Changing the dressing of the shunt daily (choice D) is a standard nursing care practice to prevent infection, but again, it is not as critical as ensuring the shunt remains patent through daily heparinization.
3. Richard is a subject of a research lead by his doctor. The nurse knows that all of the following is a correct understanding as his right as a research subject except:
- A. I can withdraw with this research even after the research has been started
- B. My confidentiality will not be compromised in this research
- C. I must choose another doctor if I withdrew from this research
- D. I can withdraw with this research before the research has been started
Correct answer: C
Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.
4. Which of the following is not a desirable blood lipid value?
- A. low total cholesterol
- B. high LDL
- C. high HDL
- D. low blood triglycerides
Correct answer: B
Rationale: The correct answer is B. High levels of LDL (low-density lipoprotein) cholesterol are undesirable as they are associated with an increased risk of cardiovascular disease. Therefore, low total cholesterol (choice A), high HDL (choice C), and low blood triglycerides (choice D) are considered desirable blood lipid values. Low total cholesterol is beneficial as high levels can increase the risk of heart disease. High HDL cholesterol is considered good as it helps remove LDL cholesterol from the arteries. Low blood triglycerides are also preferred as high levels are associated with an increased risk of heart disease.
5. Uric acid kidney stones are most commonly associated with what condition?
- A. diabetes
- B. hypercalcemia
- C. gout
- D. diarrhea
Correct answer: C
Rationale: Gout is a condition characterized by high levels of uric acid, which can lead to the formation of uric acid kidney stones due to the crystallization of uric acid in the kidneys.
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