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Question 1 of 5

The nurse is assessing a newborn delivered at home by a client addicted to heroin. Which of the following would the nurse expect to observe?

Correct Answer: D

Rationale: Jitteriness at 24-48 hours. Withdrawal signs may not be evident for 1-2 days after birth. Irritability and poor feeding also are evident.

Question 2 of 5

What socioeconomic indicators would the nurse identify as risk factors for a 2-month-old infant to develop failure to thrive (FTT)? Select all that apply.

Correct Answer: B,C,D

Rationale: Risk factors for FTT include unemployment limiting resources, caregiver cognitive disabilities impairing care, and social/emotional isolation reducing support. Working parents and unmarried status are not direct risks.

Question 3 of 5

The doctor has prescribed imipramine (Tofranil) for an elderly client with endogenous depression. The nurse should give priority to assessing the client's:

Correct Answer: B

Rationale: Imipramine, a tricyclic antidepressant, can cause cardiac arrhythmias, especially in the elderly, making cardiac status assessment a priority.

Question 4 of 5

An 80-year-old woman is having difficulty sleeping. Which nursing action is most appropriate initially?

Correct Answer: C

Rationale: Avoiding daytime naps improves nighttime sleep hygiene, a non-pharmacologic initial approach suitable for an elderly client.

Question 5 of 5

The nurse understands that a priority goal of involuntary hospitalization of the severely mentally ill client is

Correct Answer: C

Rationale: Protection from harm to self or others. Involuntary hospitalization is required for individuals who are dangerous to themselves or others.

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