Nokea
A 4 year old has an imaginary playmate, which concerns the mother. The nurse's best response would be:
- A. I understand your concern and will assist you with a referral.'
- B. Try not to worry because you will just upset your child.'
- C. Just ignore the behavior and it should disappear by age 8.'
- D. This is appropriate behavior for a preschooler and should not be a concern.'
Correct Answer: D
Rationale: This is normal for a preschooler, and a referral is not appropriate. Telling a parent not to worry is unhelpful. This response does not address the mother's concern. This response is incorrect. The behavior is normal and will usually disappear by the time the child enters school. This behavior is normal development for a preschooler.
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A client's prenatal screening indicated that she has no immunity to rubella. She is now 10 weeks pregnant. The best time to immunize her is:
- A. In the immediate postpartum period
- B. After the first trimester
- C. At 28 weeks' gestation
- D. Within 72 hours postpartum
Correct Answer: A
Rationale: The rubella vaccine is made with attenuated virus and is given in the immediate postpartal period to prevent infection during pregnancy and subsequent adverse fetal and neonatal sequelae. Mothers are advised to prevent pregnancy for 3 months following immunization. Rubella infection during the second trimester may result in permanent hearing loss for the fetus. RhoGam is the drug generally administered at 28 weeks' gestation to Rh-negative women. It is contraindicated to administer rubella vaccine during pregnancy. RhoGam is the drug administered within 72 hours postpartum to Rh-negative women to prevent the development of antibodies to fetal cells.
The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibiting a toxic reaction to:
- A. Digoxin (Lanoxin)
- B. Lidocaine (Xylocaine)
- C. Quinidine gluconate or sulfate (Quinaglute, Quinidex)
- D. Nitroglycerin IV (Tridil)
Correct Answer: B
Rationale: Side effects of digoxin include headache, hypotension, AV block, blurred vision, and yellow-green halos. Side effects of lidocaine include heart block, headache, dizziness, confusion, tremor, lethargy, and convulsions. Side effects of quinidine include heart block, hepatotoxicity, thrombocytopenia, and respiratory depression. Side effects of nitroglycerin include postural hypotension, headache, dizziness, and flushing.
The nurse is caring for a client following a cerebral vascular accident. Which portion of the brain is responsible for changes in the client's vision?
- A. Temporal lobe
- B. Frontal lobe
- C. Occipital lobe
- D. Parietal lobe
Correct Answer: C
Rationale: The occipital lobe processes visual information. A cerebral vascular accident affecting this area can cause visual deficits such as hemianopia or visual agnosia. The temporal lobe manages auditory and memory functions, the frontal lobe controls behavior and motor skills, and the parietal lobe handles sensory integration.
A client with a history of prostate cancer is admitted with complaints of bone pain. The nurse should give priority to:
- A. Monitoring for metastasis
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Bone pain in prostate cancer often indicates bone metastasis, so monitoring for metastasis is the priority.
Before administering eardrops to a toddler,the nurse should recognize that it is essential to consider which of the following?
- A. Age
- B. Weight
- C. Developmental level
- D. Ability to understand
Correct Answer: C
Rationale: The toddler’s developmental level affects cooperation and ability to follow instructions during eardrop administration. Age is a factor but less specific and weight or understanding are secondary to developmental considerations.