Nokea
The practical nurse is assisting the registered nurse in assessing a child with attention-deficit hyperactivity disorder at the clinic for a well-child visit. The client has been taking methylphenidate for a year. What are the priority nursing assessments?
- A. Attention span and activity level
- B. Dental health and mouth dryness
- C. Height/weight and blood pressure
- D. Progress with schoolwork and in making friends
Correct Answer: C
Rationale: Methylphenidate can affect growth (height/weight) and increase blood pressure (C), making these priority assessments. Attention and activity (A) are relevant but secondary. Dental health (B) and social progress (D) are less critical for medication monitoring.
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The nurse receives the handoff of care report on four clients. Which client should the nurse see first?
- A. Client reporting incisional pain of 8 on a scale of 0-10 with a respiratory rate of 25/min who had a right pneumonectomy 12 hours ago
- B. Client with a left pleural effusion who has crackles, absent breath sounds in the left base, and an SpO2 of 94% on room air
- C. Client with a temperature of 100.4 F (38 C) and a respiratory rate of 12/min who had a small bowel resection 1 day ago
- D. Client with pneumonia who has a temperature of 97.6 F (36.4 C), has an SpO2 of 93% on 4 L/min supplemental oxygen, and is becoming restless
Correct Answer: D
Rationale: Restlessness in a pneumonia client with low SpO2 (D) suggests worsening hypoxia, requiring immediate assessment. Severe pain (A) is urgent but stable. Pleural effusion (B) and fever (C) are less critical.
Which of the following activities would be best tolerated by a client with muscular dystrophy?
- A. Swimming
- B. Riding a bicycle
- C. Playing golf
- D. Skating
Correct Answer: A
Rationale: Swimming is low-impact and supports muscles, making it the best activity for a client with muscular dystrophy, which causes muscle weakness.
A client with a diagnosis of HPV is at risk for which of the following?
- A. Hodgkin's lymphoma
- B. Cervical cancer
- C. Multiple myeloma
- D. Ovarian cancer
Correct Answer: B
Rationale: The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the cancers mentioned in answers A, C, and D, so those are incorrect.
The nurse is teaching a client with cardiac disease about the anatomy and physiology of the heart. Which is the correct pathway of blood flow through the heart?
- A. Right ventricle, left ventricle, right atrium, left atrium
- B. Left ventricle, right ventricle, left atrium, right atrium
- C. Right atrium, right ventricle, left atrium, left ventricle
- D. Right atrium, left atrium, right ventricle, left ventricle
Correct Answer: C
Rationale: Right atrium, right ventricle, left atrium, left ventricle. This is the correct pathway of blood flow through the heart.
A client is being discharged after having a stent placed in the left anterior descending coronary artery. The client is prescribed clopidogrel. Which client data obtained by the nurse would be concerning in relation to this new medication?
- A. Blood pressure of 140/84 mm Hg
- B. Heart rate of 98/min
- C. Platelet count of 200,000/mm^3 (200 x 10^9/L)
- D. Report of Ginkgo biloba use
- E. Report of peptic ulcer disease
Correct Answer: D,E
Rationale: Ginkgo biloba (D) and peptic ulcer disease (E) increase bleeding risk with clopidogrel, requiring caution. Blood pressure (A), heart rate (B), and platelet count (C) are within normal limits.