Nokea
A 6-year-old child is admitted with suspected appendicitis. Which symptom should the nurse prioritize when assessing this child?
- A. Fever
- B. Nausea
- C. Rebound tenderness
- D. Diarrhea
Correct Answer: C
Rationale: Rebound tenderness in the right lower quadrant is a hallmark sign of appendicitis, indicating peritoneal irritation and requiring urgent surgical evaluation.
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Which of these skills is most closely related to successfully meeting the established priority needs of a group of clients?
- A. Time management skills
- B. Communication skills
- C. Collaboration skills
- D. Supervision skills
Correct Answer: A
Rationale: Time management skills are critical for prioritizing and addressing the needs of multiple clients efficiently, ensuring that high-priority tasks are completed in a timely manner.
The nurse is teaching a client with a new diagnosis of hyperthyroidism about medication management. Which of the following medications should the client expect to take?
- A. Methimazole.
- B. Levothyroxine.
- C. Liothyronine.
- D. Propylthiouracil.
Correct Answer: A, D
Rationale: Methimazole and propylthiouracil inhibit thyroid hormone production in hyperthyroidism.
A client with a history of type 2 diabetes mellitus is prescribed metformin (Glucophage). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild nausea.
- B. Metallic taste.
- C. Lactic acidosis symptoms.
- D. Weight gain.
Correct Answer: C
Rationale: Lactic acidosis is a rare but serious side effect of metformin, requiring immediate reporting of symptoms like muscle pain or weakness.
The nurse assists the physician in inserting a temporary pacemaker into the client. After the procedure, the nurse should verify that which of the following has been documented?
- A. The client's cardiovascular status.
- B. The client's emotional state.
- C. The type of sedation used.
- D. Pacemaker rate, type, and settings.
Correct Answer: D
Rationale: Documenting the pacemaker rate, type, and settings is critical to ensure proper function and patient safety post-procedure. While cardiovascular status and sedation are important, the pacemaker specifics are the priority for verification.
A client with a diagnosis of nephrotic syndrome states to the nurse, 'Why should I even bother trying to control my diet and the swelling? It doesn't really matter what I do if I can never get rid of this kidney problem anyway!' Which potential client problem should the nurse address based on the client's statement?
- A. Anxiety
- B. Difficulty coping
- C. Feeling powerless
- D. Negative body image
Correct Answer: C
Rationale: Feeling powerless is a problem when the client believes that personal actions will not affect an outcome in any significant way. Anxiety occurs when the client has a feeling of unease with a vague or undefined source. Difficulty coping indicates that the client has impaired adaptive abilities or behaviors in meeting the demands or roles expected from the individual. Negative body image occurs when the way the client perceives body image is altered.