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Questions 163

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Question 1 of 5

The nurse is caring for a newborn. Which of the following signs would indicate neonatal abstinence syndrome? Select all that apply.

Correct Answer: A,D,E

Rationale: Neonatal abstinence syndrome includes irritability , nasal congestion and sneezing , and poor feeding with loose stools due to withdrawal. Meconium ileus and hypotonia suggest cystic fibrosis, and microcephaly and cleft palate are congenital anomalies.

Question 2 of 5

The clinic nurse is preparing to administer an allergy immunotherapy injection to a client recently initiated on the therapy. Which statement by the client indicates a need for further teaching?

Correct Answer: A

Rationale: Leaving immediately after an allergy shot is unsafe due to the risk of delayed anaphylaxis, requiring a 20–30 minute observation period. Weekly shots , reporting hives , and mild redness are appropriate.

Question 3 of 5

A client is in suspected shock state from major trauma. Which of the following parameters indicate the adequacy of peripheral perfusion? Select all that apply.

Correct Answer: B,E

Rationale: Capillary refill time and skin color/temperature directly assess peripheral perfusion in shock. Apical pulse , lung sounds , and pupillary response evaluate other aspects.

Question 4 of 5

The nurse is discussing mammogram screening with a family. No one in the family has had a mammogram. The mother is 52, there are four daughters, ages 10, 15, 21, and 34, and the grandmother is 75. Which of the following women should receive a mammogram? Select all that apply.

Correct Answer: D,E,F

Rationale: Women aged 40 and older, or earlier with risk factors, should have mammograms. The 34-year-old, 52-year-old, and 75-year-old women meet screening age criteria.

Question 5 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.

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