The nurse is calculating the one-minute Apgar score for a newborn infant and determines that the heart rate is 150 beats/minute, a vigorous cry is present, muscle tone is good with total flexion, quick reflex irritability noted, and skin color is dusky and cyanotic.

Which Apgar score should the nurse assign to this infant?

(Enter numeric value only.)

Answer and Explanation

The Correct Answer is ["9"]

To determine the Apgar score for the newborn infant, we assess five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each parameter is scored from 0 to 2, with 2 being the highest score. Let's evaluate each parameter:

Heart rate: 150 beats/minute --> Score of 2.
Respiratory effort: Vigorous cry present --> Score of 2.
Muscle tone: Good muscle tone with total flexion --> Score of 2.
Reflex irritability: Quick reflex irritability noted --> Score of 2.
Color: Dusky and cyanotic skin color --> Score of 1.

Now, we sum up the scores: 2+2+2+2+1=92+2+2+2+1=9

Therefore, the Apgar score for this infant is 9.

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Correct Answer is B

Explanation

A. "I cough a lot at night and it keeps me up half the night." Night-time coughing can be associated with various conditions, including asthma, GERD, or postnasal drip, but it is not specifically indicative of orthopnoea.

B. "I sleep on three pillows at night." This supports orthopnoea, which is difficulty breathing when lying flat. Clients with orthopnoea often use multiple pillows to elevate their upper body to alleviate shortness of breath.

C. "I have multiple attacks of wheezing almost daily." Frequent wheezing is more indicative of asthma or other obstructive airway diseases, not orthopnoea.

D. "It doesn't take much activity before I'm out of breath." This describes dyspnoea on exertion, which is different from orthopnoea, as it refers to difficulty breathing during physical activity rather than when lying down.

A. Assess daily alcohol intake. B. Identify signs of depression. C. Determine cognitive status. D. Review risk factors for abuse.

Correct Answer is C

Explanation

A. Assess daily alcohol intake: Alcohol misuse can contribute to a variety of psychiatric symptoms, including hallucinations or delusions. Older adults may metabolize alcohol differently, leading to higher susceptibility to its effects. While this is important, it may not be the first priority unless there are clear signs of alcohol misuse (e.g., smell of alcohol, history provided by the client or family).

B. Identify signs of depression: Depression in older adults can sometimes present with psychotic features, including hallucinations or delusions. Understanding the client's emotional state and identifying symptoms of depression can provide insight into the cause of their behaviour. Depression is common in older adults and can be a precursor or a component of other psychiatric conditions.

C. Determine cognitive status: Cognitive impairment (e.g., dementia) can often present with hallucinations or delusions, and evaluating cognitive status can help differentiate between different types of disorders (e.g., dementia vs. primary psychotic disorders). Assessing cognitive function helps in identifying conditions like Alzheimer's disease or other dementias where hallucinations can be a symptom. This assessment can guide the further direction of evaluation and treatment, making it a critical first step.

D. Review risk factors for abuse: Older adults are at risk of abuse, which can include physical, emotional, and financial abuse. Identifying these risk factors is crucial for their safety and well-being. While this is a significant concern, unless there are immediate signs or disclosures of abuse, it may not be the most urgent assessment in the context of hallucinations.

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Naxlex Comprehensive Predictor Exams

Which subjective assessment data supports the nurse's conclusion that a client is experiencing orthopnea?

Correct Answer is B

Explanation

An older adult client who has been talking to the client's deceased mother is referred to the psychiatric clinic for an evaluation. Which assessment should the nurse complete first?

Correct Answer is C

Explanation

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