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Question 1 of 5.

Which of the following blood values would require further nursing action in a newborn who is 4 hours old?

A. Hemoglobin 17.2 g/dL

B. Platelets 250,000/mm3

C. Serum glucose 30 mg/dL

D. White blood cells 18,000/mm3

Explanation: A serum glucose of 30 mg/dL in the first 72 hours of life is indicative of hypoglycemia and warrants further intervention.

Question 2 of 5.

The physician has ordered a low-residue diet for a client with Crohn's disease. Which food is not permitted in a low-residue diet?

A. Mashed potatoes

B. Smooth peanut butter

C. Fried fish

D. Rice

Explanation: A low-residue diet minimizes fiber and irritating foods; fried fish is high in fat and can irritate the gut, making it unsuitable for Crohn's disease.

Question 3 of 5.

The physician has ordered Eskalith (lithium carbonate) 500 mg three times a day and Risperdal (risperidone) 2 mg twice daily for a client admitted with bipolar disorder, acute manic episodes. The best explanation for the client's medication regimen is:

A. The client's symptoms of acute mania are typical of undiagnosed schizophrenia.

B. Antipsychotic medication is used to manage behavioral excitement until mood stabilization occurs.

C. The client will be more compliant with a medication that allows some feelings of hypomania.

D. Antipsychotic medication prevents psychotic symptoms commonly associated with the use of mood stabilizers.

Explanation: Risperidone, an antipsychotic, is used to control acute manic symptoms like agitation, while lithium stabilizes mood over time, addressing the immediate behavioral excitement.

Question 4 of 5.

Which one of the following situations represents a maturational crisis for the family?

A. A four-year-old entering nursery school

B. Development of preeclampsia during pregnancy

C. Loss of employment and health benefits

D. Hospitalization of a grandfather with a stroke

Explanation: A maturational crisis involves normal developmental transitions, such as a child entering nursery school, which can stress family dynamics.

Question 5 of 5.

The nurse is making room assignments for four obstetrical clients. If only one private room is available, it should be assigned to:

A. A multigravida with diabetes mellitus

B. A primigravida with preeclampsia

C. A multigravida with preterm labor

D. A primigravida with hyperemesis gravidarum

Explanation: Preeclampsia requires close monitoring due to risks like seizures or stroke, making a private room essential for a primigravida with this condition.

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