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Questions 164

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Extract:


Question 1 of 5

A 3-month-old infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action?

Correct Answer: C

Rationale: A spiral fracture in a non-mobile infant is inconsistent with rolling off a bed, suggesting abuse. Reporting is the priority to ensure safety. Documentation , questioning , and separation follow.

Question 2 of 5

All of the following clients are on the unit. Which one is most likely to develop urinary retention?

Correct Answer: C

Rationale: Abdominal hysterectomy involves pelvic manipulation, increasing urinary retention risk due to bladder trauma or nerve disruption. Other surgeries pose lower risk.

Question 3 of 5

The nurse is observing the parent feed a 3-month-old diagnosed with gastroesophageal reflux. Which action by the parent indicates that further teaching is necessary?

Correct Answer: B

Rationale: Active play post-feeding can worsen reflux. Not forcing the bottle , burping , and upright positioning are appropriate.

Question 4 of 5

A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?

Correct Answer: D

Rationale: HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and low platelets. Elevated hepatic enzymes are a key finding, so D is correct. Answers A, B, and C are not associated with HELLP syndrome.

Question 5 of 5

The nurse is caring for an adult who had a cerebrovascular accident. The nurse gives the client a washcloth and encourages the client to wash her face. The client looks at the washcloth as though she does not know what to do with it. The nurse knows that this indicates that the client has which of the following?

Correct Answer: C

Rationale: Agnosia is the inability to recognize objects, like a washcloth, despite intact sensory function, common post-CVA, unlike apraxia (motor planning), aphasia (language), or dysarthria (speech articulation).

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