An Asian family arrives with their newborn for a well visit. When assessing the infant, the nurse observes the following skin irregularity. What is the nurse's priority action?

Notify child protective services

Record the finding

Notify the healthcare provider

Interview the clients about the injury

Answer and Explanation

The Correct Answer is B

Choice A Reason: Notifying child protective services is not the priority action, as it is not indicated by the skin irregularity. The skin irregularity is most likely a Mongolian spot, which is a benign, bluish-gray or purple patch of pigmentation that is common in infants of Asian, African, or Hispanic descent. It is not a sign of abuse or injury, but rather a normal variation of skin color.

Choice B Reason: This is the correct choice. Recording the finding is the priority action, as it documents the presence and location of the Mongolian spot and prevents confusion or misdiagnosis in the future. The Mongolian spot usually fades by age 2 to 4 years, but it may persist into adulthood.

Choice C Reason: Notifying the healthcare provider is not the priority action, as it is not necessary for the skin irregularity. The skin irregularity is not a cause for concern or intervention, but rather a normal variation of skin color.

Choice D Reason: Interviewing the clients about the injury is not the priority action, as it is not appropriate for the skin irregularity. The skin irregularity is not an injury, but rather a normal variation of skin color. Interviewing the clients about it may imply suspicion or accusation of abuse, which can damage the nurse-client relationship and trust.

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Correct Answer is A

Explanation

Choice A Reason: This is correct because the patient's Glasgow Coma Scale score is 9. The Glasgow Coma Scale is a tool that assesses the level of consciousness of a patient with a head injury by measuring three parameters: eye opening, verbal response, and motor response. The patient's eye opening score is 3 (opens eyes to verbal command), verbal response score is 4 (confused speech), and motor response score is 2 (withdraws from pain). The total score is the sum of these three scores, which is 9.

Choice B Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 11. To get a score of 11, the patient would need to have a higher motor response score, such as 4 (withdraws to touch) or 5 (localizes to pain).

Choice C Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 15. To get a score of 15, the patient would need to have the highest scores for all three parameters, such as 4 (opens eyes spontaneously), 5 (oriented speech), and 6 (obeys commands).

Choice D Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 13. To get a score of 13, the patient would need to have a higher verbal response score, such as 5 (oriented speech).

A. Slow cautious behaviors. B. Loss of depth perception. C. Overestimation of abilities. D. Hemianopsia.

Correct Answer is D

Explanation

Choice A reason: This is incorrect because slow cautious behaviors are more consistent with a stroke involving the right hemisphere. The right hemisphere controls spatial awareness, creativity, and intuition. A stroke affecting this hemisphere can cause impulsivity, poor judgment, and denial of deficits.

Choice B reason: This is incorrect because loss of depth perception is more consistent with a stroke involving
the right hemisphere. The right hemisphere controls visual-spatial perception, which includes depth perception, distance estimation, and object recognition. A stroke affecting this hemisphere can cause difficulty in navigating space, judging distances, and identifying objects.

Choice C reason: This is incorrect because the overestimation of abilities is more consistent with a stroke involving
the right hemisphere. The right hemisphere controls emotional regulation, self-awareness, and insight. A stroke affecting this hemisphere can cause euphoria, lack of insight, and unrealistic expectations.

Choice D reason: This is the correct answer because hemianopsia is consistent with a stroke involving
the left hemisphere. The left hemisphere controls language, logic, and analysis. A stroke affecting this hemisphere can cause hemianopsia, which is the loss of vision in half of the visual field. This can affect reading, writing, and communication skills.

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An Asian family arrives with their newborn for a well visit. When assessing the infant, the nurse observes the following skin irregularity. What is the nurse's priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with a head injury opens his eyes to verbal stimulation, shouts out when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How would the nurse record the patient's Glasgow Coma Scale score?

Correct Answer is A

Explanation

A nurse is caring for a client who has suffered a stroke involving the left hemisphere. Which of the following alterations in function are consistent with this type of stroke?

Correct Answer is D

Explanation

A nurse is assisting a client with a visual impairment to use the restroom. Which of the following actions will the nurse take to prevent complications?

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?

A nurse is preparing to review discharge instructions with a client who reports having hearing loss. Which of the following actions should the nurse plan to take?

A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?

A nurse caring for a client with acute peritonitis reviews the physician's orders. The orders include an NPO diet, insertion of a nasogastric tube set to low intermittent suction, and IV fluids at 50 mL per hour. When asked why he will need the NG tube, what is the nurse's best reply?

A nurse caring for a client with hepatitis is providing education to the client about portal hypertension. Which of the following will the nurse include in the teaching?

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?

A client with a new diagnosis of trigeminal neuralgia is receiving education to prevent triggering an acute onset. Which of the following will the nurse include in teaching?