Which newborn assessment finding would require the nurse to report to the health care provider?

The newborn who has cyanotic hands and feet.

The newborns whose head turns toward the cheek being stroked

The newborn whose toes curl when the lateral heel is stroked

The newborn who extends the arms when hearing a loud noise

Answer and Explanation

The Correct Answer is A

A. The newborn who has cyanotic hands and feetCyanosis, a bluish or purplish discoloration of the skin, in the hands and feet of a newborn can indicate a breathing problem or poor circulation. This requires prompt evaluation by a healthcare provider.
B. The newborn whose head turns toward the cheek being stroked. This describes the rooting reflex, which is normal.
C. The newborn whose toes curl when the lateral heel is stroked. This describes the Babinski reflex, which is also normal for infants.
D. The newborn who extends the arms when hearing a loud noise. This describes the Moro reflex, which is normal and should not require reporting.

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Correct Answer is B

Explanation

A. Ensuring that the client takes care of their ADLS to prevent dependence: While promoting independence is important, ensuring safety is a higher priority to prevent immediate harm.
B. Ensuring that the client environment is safe to prevent injury: Safety is the top priority for clients with Alzheimer's due to their increased risk of falls, wandering, and other accidents. A safe environment helps prevent injuries.
C. Ensuring that the client receives food they like to prevent anxiety: Although providing familiar and preferred foods can reduce anxiety, it is not as critical as ensuring a safe environment.
D. Ensuring that the client meets the other patients to prevent social isolation: Social interaction is beneficial, but ensuring safety takes precedence to prevent potential harm.

Correct Answer is []

Explanation

Potential Condition

Bulimia nervosa: The client has a BMI of 18.5, which is on the lower end of normal, indicating possible weight issues, but not the severe underweight typical of anorexia nervosa. The client describes cycles of binge eating followed by compensatory behaviors such as purging (using laxatives), which are characteristic of bulimia nervosa. The client expresses a preoccupation with food and body weight, and feelings of embarrassment about their eating habits, which align with bulimia nervosa.

Actions to Take

1. Assess binging and purging patterns: It's crucial to understand the frequency, triggers, and methods of binging and purging to tailor interventions effectively and to monitor the severity and progression of bulimia.

2. Encourage client to identify triggers for overeating: Identifying triggers for binging can help the client develop healthier coping mechanisms and reduce the occurrence of binge eating episodes.

Parameters to Monitor

1. Electrolyte levels: Frequent use of laxatives and purging behaviors can lead to electrolyte imbalances, which are potentially life-threatening and must be monitored regularly.

2. Frequency of compensatory behaviors: Tracking the frequency of purging behaviors (such as laxative use) helps assess the effectiveness of interventions and the client’s progress in reducing harmful behaviors.

Incorrect answers:

Actions to Take:

Assess for and discourage provocative or seductive behaviour: This is more relevant to histrionic personality disorder, not bulimia nervosa.
Weigh daily for the first week: While weighing the client can be part of the monitoring process, daily weigh-ins can increase anxiety and may not directly address the core issues of bulimia.
Assess for consumption of right food items: While dietary intake is important, focusing solely on food items without addressing the psychological aspects may not be effective for treating bulimia.

Parameters to Monitor:

Attention-seeking behaviours: More relevant to histrionic personality disorder than bulimia nervosa.
Signs of infection: Not directly relevant unless there is evidence of a related health issue or a compromised immune system, which is not indicated in the provided information.
Presence of lanugo: Lanugo is more commonly associated with anorexia nervosa due to severe malnutrition, not bulimia.

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Which newborn assessment finding would require the nurse to report to the health care provider?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is being admitted to the hospital with a neurocognitive disease due to Alzheimer's disease. Which action by the nurse is the priority?

Correct Answer is B

Explanation

Correct Answer is []

Explanation

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