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 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.

A. Depth perception B. Peripheral vision C. Color deficit D. Double vision

Correct Answer is B

Explanation

Choice A Reason: Depth perception is the ability to judge the distance and position of objects in three-dimensional space. Depth perception is assessed by asking the client to touch the tip of a pen or pencil held by the nurse, or by using a stereopsis test.

Choice B Reason: Peripheral vision is the ability to see objects and movements outside the direct line of vision. Peripheral vision is assessed by asking the client to shake the hand of the nurse, who stands at an angle to the client's side, or by using a confrontation test.

Choice C Reason: Color deficit is the inability to distinguish certain colors or shades of colors. Color deficit is assessed by asking the client to identify numbers or shapes on a color plate test, such as the Ishihara test.

Choice D Reason: Double vision is the perception of two images of a single object. Double vision is assessed by asking the client to cover one eye and look at an object, then switch eyes and compare the images, or by using a cover-uncover test.

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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 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 performing a focused assessment for a client's vision. What visual assessment is the nurse making when she extends her hand for the client to shake?

Correct Answer is B

Explanation

The nurse observes the client as he walks into the clinic. She notices a slight tremor of the hands, slowness of movements, and a mask-like facial expression, with postural instability. Which of the following in the client's history are consistent with these observations?

A client with red scaling papules on his elbows, knees, lower back, and scalp arrives to the clinic. Which of the following questions will the nurse include in her assessment?

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A client's chart indicates that they are legally blind. Which of the following is the definition of legally blind?

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

Which of the following clients is most at risk for traumatic brain injury?

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