A nurse is collecting data from a newborn who was born 24 hrs ago. Which of the following images should the nurse identify as an indication that the newborn has erythema toxicum?

Answer and Explanation

The Correct Answer is B

A: Image A shows a newborn wrapped in a blanket with generalized redness on the face but without distinct blotchy areas or pustules. This appearance is more consistent with normal transitional skin changes such as acrocyanosis or overall mild skin redness after birth. It does not match the appearance of erythema toxicum.

B: Image B shows a close-up of the newborn’s face with visible small red blotchy spots, especially around the cheeks and nose. This matches the classic presentation of erythema toxicum, a benign newborn rash appearing within the first 24 hours. It is characterized by red patches with possible small pustules scattered over the face and body.

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Correct Answer is ["A","B","C"]

Explanation

3-month history of unplanned weight loss, increased sweating, heat intolerance, fatigue, and difficulty sleeping: These symptoms are classic for hyperthyroidism and suggest worsening metabolic imbalance. They require follow-up because untreated hyperthyroidism can lead to serious complications like thyroid storm.
Reports last menstrual period was 3 months ago: Amenorrhea or menstrual irregularities are common in hyperthyroidism due to hormonal disruption. This finding supports the diagnosis and needs follow-up for endocrine and reproductive health management.
Exophthalmos noted: Exophthalmos, or bulging eyes, is associated with Graves' disease and indicates autoimmune involvement affecting the orbital tissues. It can lead to complications like corneal ulceration or vision loss if severe and thus requires ophthalmologic evaluation.
Goiter visualized on neck: A visible goiter reflects thyroid gland enlargement, often due to hyperstimulation from excess thyroid hormones. It requires ongoing monitoring to assess for airway compromise, dysphagia, or further gland enlargement.
Client’s partner reports irritability and anxiety: Behavioral and mood changes like irritability and anxiety are manifestations of hyperthyroidism affecting neurological function. Persistent symptoms can impair quality of life and must be addressed as part of comprehensive treatment planning.

A. "I will support your decision and help you explain it to others.” B. "Let me explain the pros and cons of your decision” C. “I suggest you discuss this decision with your family first” D. “I will send the social worker in to discuss this decision with”

Correct Answer is A

Explanation

A. "I will support your decision and help you explain it to others.": This response respects the client's autonomy and decision-making rights. It also offers emotional support and assistance in communicating the client's wishes to other healthcare team members or family, promoting dignity and advocacy.

B. "Let me explain the pros and cons of your decision.": This response may sound judgmental and suggest that the nurse is trying to influence the client's decision. Once a competent client has made a choice, the nurse’s role is to support it rather than attempt to persuade or second-guess it.

C. "I suggest you discuss this decision with your family first.": While family discussions can be valuable, the client has the primary right to make healthcare decisions. Suggesting they must discuss it with family could delay honoring the client’s wishes or create unnecessary emotional pressure.

D. "I will send the social worker in to discuss this decision with you.": While a social worker can provide additional support, immediately deferring to someone else instead of acknowledging the client’s decision can make the client feel dismissed. The nurse should first validate and support the client’s expressed wishes.

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A nurse is collecting data from a newborn who was born 24 hrs ago. Which of the following images should the nurse identify as an indication that the newborn has erythema toxicum?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

A nurse is caring for a client who has lung cancer. The client tells the nurse they do not want to be resuscitated in the event of a cardiac arrest. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A male nurse is assigned to care for an older adult female client. The client tells the nurse that she wants a female nurse to care for her. Which of the following statements should the nurse make?

A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

A nurse is caring for a client who has a chlamydial infection and a new prescription for doxycycline. The client reports nausea and vomiting after starting the medication. Which of the following recommendations should the nurse make?

A nurse is assisting with the care of a client who is receiving a PCA pump following a hysterectomy. Which of the following findings should the nurse identify as an indicator of unrelieved pain?

A nurse is assisting in the care of a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy?

A nurse is assisting in the care of a group of clients. Which of the following occurrences should the nurse identify as requiring an incident report?

A nurse is supervising an assistive personnel (AP) who is providing client care. The nurse should identify that which of the following actions by the AP demonstrates effective use of supplies?

An 18-year-old client in the emergency department is scheduled for an appendectomy. Although the client's parents advocate for the surgery, the client declines the procedure. Which of the following ethical principles is the nurse displaying by respecting the client's decision?