Nokea
A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78 BPM; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity?
- A. Bradycardia
- B. Lethargy
- C. Irritability
- D. Vomiting
Correct Answer: A
Rationale: Bradycardia. The most common sign of digoxin toxicity in children is bradycardia (heart rate below 100 BPM in an infant).
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A 3 year-old child is brought to the clinic by his grandmother to be seen for 'scratching his bottom and wetting the bed at night.' Based on these complaints, the nurse would initially assess for which problem?
- A. allergies
- B. scabies
- C. regression
- D. pinworms
Correct Answer: D
Rationale: Pinworms are a common cause of anal itching and can contribute to bed-wetting in children due to discomfort. The nurse should assess for signs of pinworm infection, such as observing the anal area for worms or performing a tape test.
A 25-year-old primigravida with type I diabetes mellitus.
The nurse explains to the client that her insulin needs will
- A. increase during pregnancy and decrease after delivery.
- B. decrease during pregnancy and increase after delivery.
- C. increase during pregnancy and remain increased after delivery.
- D. decrease during pregnancy and fluctuate after delivery.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-needs increase during pregnancy due to hormonal interference in glucose metabolism (2) needs increase during pregnancy due to hormonal interference in glucose metabolism (3) insulin needs will decrease after delivery (4) needs increase during pregnancy
The nurse is teaching a client with a new diagnosis of gout about allopurinol (Zyloprim). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any skin rash.
- C. Stop the medication if gout attacks cease.
- D. Avoid drinking plenty of water.
Correct Answer: B
Rationale: A skin rash may indicate a hypersensitivity reaction to allopurinol, requiring immediate reporting. Options A, C, and D are incorrect.
The nurse caring for a 14 year-old boy with severe Hemophilia A, who was admitted after a fall while playing basketball. In understanding his behavior and in planning care for this client, the nurse should understand that adolescents with hemophilia
- A. Must have structured activities
- B. Often take part in active sports
- C. Explain limitations to peers
- D. Avoid risks after bleeding episodes
Correct Answer: B
Rationale: Often take part in active sports. Adolescents with hemophilia may engage in sports, requiring careful monitoring to prevent bleeding.
A client with a reactive depression has the greaTest chance of success in activities that require psychic and physical energy if the nurse schedules activities in the
- A. morning hours.
- B. middle of the day.
- C. afternoon hours.
- D. evening hours.
Correct Answer: A
Rationale: client with reactive depression has the highest level of physical and psychic energy in the morning