Nokea
A 5-year-old boy is brought to the emergency room after ingesting a bottle of baby aspirin. The nurse should observe the boy for which of the following signs and symptoms?
- A. Nausea and vertigo.
- B. Epistaxis and paralysis.
- C. Dysrhythmia and hypoventilation.
- D. Tinnitus and gastric distress.
Correct Answer: D
Rationale: symptoms of overdose
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Which of the following activities documented by the recreational therapist following a community reorientation outing for a paraplegic client would indicate to the nurse a readiness for discharge?
- A. The client states that he/she enjoyed being outside the hospital environment.
- B. The client was able to participate in a structured team sport by keeping score.
- C. The client was independently able to order his meal and feed himself.
- D. The client was independent in transfers and wheelchair mobility.
Correct Answer: D
Rationale: correct, physical, these skills are requisite for discharge
A client with a statement indicating the use of a defense mechanism.
Which of the following statements, if made by a client to the nurse, would indicate that the client is using the defense mechanism of conversion?
- A. I love my family with all my heart even though they don't love me.'
- B. I was unable to take my final exams because I was unable to write.'
- C. I don't believe I have diabetes. I feel perfectly fine.'
- D. If my wife was a better housekeeper I wouldn't have such a problem.'
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) indicates reaction formation (2) correct-client has converted his anxiety over school performance into a physical symptom that interferes with his ability to perform (3) indicates denial (4) indicates projection
A client has a bovine graft inserted into the left arm for hemodialysis. During the immediate postoperative period, which of the following actions, if performed by the nurse, is BEST?
- A. Restart the IV above the level of the graft.
- B. Take blood pressures only on the right arm.
- C. Elevate the left arm above the level of the heart.
- D. Check the radial pulse on the left arm q 4h.
Correct Answer: B
Rationale: BP should always be taken on the opposite arm from the graft
Which of the following statements, if made to the nurse, indicates parental understanding about the cause of their newborn's diagnosis of cystic fibrosis (CF)?
- A. The gene came from my husband's side of the family.
- B. The gene came from my wife's side of the family.
- C. There is a 50 percent chance that our next child will have the disease.
- D. Both of us carry a recessive trait for cystic fibrosis.
Correct Answer: D
Rationale: cystic fibrosis is inherited by an autosomal recessive trait
The nurse is caring for a client who is receiving IV fluids at 150 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 140/90 mmHg.
- B. Heart rate of 90 bpm.
- C. Crackles in the lung bases.
- D. Urine output of 100 mL/hour.
Correct Answer: C
Rationale: Crackles in the lung bases suggest fluid overload, a serious complication of IV fluids, potentially leading to pulmonary edema. Options A, B, and D are normal or less concerning: blood pressure 140/90 mmHg and heart rate 90 bpm are stable, and urine output 100 mL/hour is adequate.