A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5°C (90.5° F). Which of the following data is the priority for the nurse to monitor?

Muscle strength

Urinary output

Pain sensation

Heart rhythm

Answer and Explanation

The Correct Answer is D

The correct answer is D. Heart rhythm. Hypothermia can cause cardiac dysrhythmias such as bradycardia, atrial fibrillation, and ventricular fibrillation, which can lead to cardiac arrest.

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Correct Answer is C

Explanation

The correct answer is C.

Hypertension. The rationale is that oral contraceptives contain synthetic hormones that can increase blood pressure and increase the risk of

cardiovascular events such as stroke, heart attack or blood clots. The nurse should advise the client to avoid oral contraceptives if she has hypertension or other risk factors for cardiovascular disease and suggest alternative methods of birth control.

A. Anterior fontanel closed B. Plays with toes C. Posterior fontanel closed D. Moves objects to mouth

Correct Answer is A

Explanation

The correct answer is A. Anterior fontanel closed. The anterior fontanel is one of two soft spots on an infant's skull that allow for brain growth and development. The anterior fontanel normally closes between 9 and 18 months of age. If it closes earlier than expected, it may indicate a condition called craniosynostosis, which is when the skull bones fuse prematurely and restrict brain growth. This can lead to increased intracranial pressure, developmental delays, and abnormal head shape. Therefore, if a nurse observes that a 4-month-old infant has a closed anterior fontanel, they should notify the provider for further evaluation. The other options are normal developmental milestones for a 4-month-old

infant and do not require notification of the provider.

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A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5°C (90.5° F). Which of the following data is the priority for the nurse to monitor?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a female client who reports she wants to begin taking oral contraceptives. Which of the following findings is a contraindication for this client?

Correct Answer is C

Explanation

A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?

Correct Answer is A

Explanation

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