you are performing a neurological assessment of your adolescent patient the patient has the moro reflex how should you interpret this neurological ass
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Leadership and Management HESI Quizlet

1. You are performing a neurological assessment of your adolescent patient. The patient has the Moro reflex. How should you interpret this neurological assessment finding?

Correct answer: D

Rationale: The Moro reflex, also known as the startle reflex, is typically present in infants up to around 4-6 months of age and is characterized by the infant's response to a sudden loss of support or loud noise. It is not a normal finding in adolescents or older individuals. Therefore, if an adolescent patient exhibits the Moro reflex during a neurological assessment, it is considered abnormal and warrants further evaluation. Choices A, B, and C are incorrect because the Moro reflex is not expected or normal among adolescents and does not specifically indicate the status of either the peripheral or central nervous system in this age group.

2. What percentage of term newborns have a congenital heart disease due to environmental risk factors such as maternal alcoholism or drug ingestion?

Correct answer: A

Rationale: The correct answer is A: 2% to 4%. According to research, 2% to 4% of term newborns have congenital heart disease due to environmental risk factors such as maternal alcoholism or drug ingestion. Choices B, C, and D provide percentages that are higher than the actual prevalence of congenital heart disease in newborns caused by environmental factors, making them incorrect.

3. Which of the following is true regarding the Affordable Care Act?

Correct answer: D

Rationale: The correct answer is D. The Affordable Care Act attempted to address many issues relevant to nursing, such as mandatory overtime, incivility, and high workloads, but it faced significant controversy. Choice A is incorrect as the act did not address nursing issues without controversy. Choice B is incorrect as it inaccurately lists the issues the act addressed. Choice C is incorrect as it does not fully capture the controversy surrounding the Affordable Care Act.

4. Select a myth or falsehood relating to pain, pain management, and addiction.

Correct answer: A

Rationale: The correct answer is A because addiction cannot be accurately predicted. Choices B and C are incorrect. Withdrawal, drug tolerance, and physical dependence are not definitive signs of addiction, and pain medications can be used with patients who have a substance abuse history under careful monitoring. Choice D is incorrect because addiction is not solely signaled by deception and stockpiling; it is a complex condition with various behavioral, physical, and psychological aspects.

5. A nurse at a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?

Correct answer: D

Rationale: The correct answer is to implement rounds every 2 hours during the day to offer toileting. This intervention helps prevent falls by addressing the common cause of unassisted mobility, which is the need to use the bathroom. Choice A is incorrect as restraints should not be the first choice for fall prevention due to the risk of injury and loss of independence. Choice B is incorrect because all side rails up can lead to entrapment and should only be used based on individualized assessments. Choice C may not be feasible for all residents over 85 years old and does not directly address the risk of falls.

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