Extract:

Question 1 of 5

Which of the following outcomes is most appropriate for a nursing diagnosis of Ineffective tissue perfusion related to interruption of arterial flow? Select all that apply.

Correct Answer: A,C,D

Rationale: Warm extremities, reduced muscle pain, and self-care participation indicate improved perfusion; respiratory outcomes are unrelated.

Question 2 of 5

The nurse is assessing teenaged girls at a well child clinic. The nurse should describe the girl shown in the figure as having:

A. Normal posture B. Kyphosis C. Scoliosis D. Lordosis

Correct Answer: C

Rationale: Scoliosis is characterized by a lateral curvature of the spine, which may be observed in a teenager. Kyphosis involves forward curvature, lordosis involves inward lumbar curvature, and normal posture lacks these abnormalities.

Question 3 of 5

The nurse is caring for a neonate with respiratory distress syndrome. Which intervention should the nurse anticipate?

A. Administer surfactant B. Provide high-flow oxygen C. Initiate antibiotic therapy D. Perform chest physiotherapy

Correct Answer: A

Rationale: Surfactant administration is the primary treatment for respiratory distress syndrome in neonates, improving lung compliance and oxygenation.

Question 4 of 5

The mother of a neonate delivered at 36 weeks' gestation asks why the neonate is being treated for sepsis when no infection is present. Which of the following responses by the nurse is most appropriate?

A. The neonate may have an infection that we haven't identified yet.' B. Premature neonates are more susceptible to infections.' C. This is a precautionary measure because the neonate is premature.' D. Antibiotics are given to all neonates born before 37 weeks.'

Correct Answer: C

Rationale: Treating a 36-week neonate for sepsis is often precautionary due to their increased risk of infection, even without confirmed infection, to prevent complications.

Question 5 of 5

The nurse is reviewing the care plan of a client diagnosed with having the deficits associated with a right-sided stroke. The nurse notes documentation that the client has unilateral neglect with left-sided deficits. The nurse plans care with the understanding that which action would be least helpful?

A. Place bedside articles on the left side. B. Approach the client from the right side. C. Teach the client to scan the environment. D. Move the commode and chair to the left side.

Correct Answer: B

Rationale: Unilateral neglect is an unawareness of the paralyzed side of the body, which increases the client's risk for injury. The nurse's role is to refocus the client's attention to the affected side. Personal care items, belongings, a bedside chair, and a commode are all placed on the affected side. The client is taught to scan the environment to become aware of that half of the body and is approached on that side by family and caregivers as well.