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Questions 158

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Question 1 of 5

A newborn girl's father expresses concern that the newborn does not have good control of her hands and arms. It is important for the father to realize certain neurological patterns that characterize the newborn:

Correct Answer: C

Rationale: Term neonates are predominantly in a flexed position with strong active muscle tone that increases. Newborns are slightly hypertonic. Neonatal movements may be jerky and uncoordinated as the neonate works against gravity in contrast to the buoyancy of the amniotic fluid. Jerky movements must be differentiated from the tremors of hypoglycemia, hypocalcemia, and neurological dysfunction. Growth of the newborn progresses in a cephalocaudal, proximal-distal fashion. Knowledge regarding infant development may facilitate parental involvement and infant stimulation. Asymmetrical movements of the extremities are indicative of neurological dysfunction.

Question 2 of 5

The nurse is teaching about irritable bowel syndrome (IBS). Which of the following would be most important?

Correct Answer: A

Rationale: A balanced diet with adequate fiber (soluble for IBS) helps regulate bowel function and reduce IBS symptoms. High fluid intake with meals may exacerbate symptoms, low-fiber diets can worsen constipation, and limiting fruits/vegetables is not advised.

Question 3 of 5

Which finding in the patient's history contraindicates the use of Imitrex (sumatriptan) for the prevention of migraine headaches?

Correct Answer: B

Rationale: Sumatriptan (Imitrex) is a vasoconstrictor contraindicated in patients with angina due to the risk of coronary artery vasoconstriction and ischemia. Diabetes renal calculi and peptic ulcer disease are not contraindications for sumatriptan.

Question 4 of 5

A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:

Correct Answer: A

Rationale: Cholinergic crisis, often from excessive anticholinesterase medication, causes parasympathetic overstimulation, leading to decreased blood pressure and constricted pupils.

Question 5 of 5

An appropriate nursing intervention for the client with borderline personality disorder is:

Correct Answer: A

Rationale: Clients with borderline personality disorder often experience mood instability and are at risk for self-harm or suicide. Observing for signs of depression or suicidal thinking is a priority nursing intervention to ensure safety. Allowing the client to lead group sessions or select a caregiver may reinforce manipulative behaviors, and restricting activity to the unit is not typically therapeutic unless specified for safety.

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