Nokea
A 6-year-old with cerebral palsy functions at the level of an 18-month-old. Which finding would support that assessment?
- A. She dresses herself
- B. She pulls a toy behind her
- C. She can build a tower of eight blocks
- D. She can copy a horizontal or vertical line
Correct Answer: B
Rationale: The correct answer is 'She pulls a toy behind her.' This behavior is consistent with the developmental stage of an 18-month-old who enjoys push-pull toys. Dressing oneself usually begins around 3 years old, building a tower of eight blocks at approximately 3 years old, and copying a horizontal or vertical line at about 4 years old. Choices A, C, and D are incorrect as they represent skills that are typically observed in older children.
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A client reports that someone is in the room and trying to kill him. The nurse's best response is:
- A. "No one is in your room. Let's get you more medicine."?
- B. "I do not see anyone, but you seem to be very frightened."?
- C. "No one can hurt you here."?
- D. "Just tell the person to go away."?
Correct Answer: B
Rationale: When a client reports hallucinations or delusions, it is crucial to respond in a non-confrontational and empathetic manner. Choice B acknowledges the client's fear without confirming the delusion, showing understanding, and providing reassurance. This response validates the client's feelings without reinforcing the false belief. The other responses in choices A, C, and D dismiss the client's feelings or perceptions, which can escalate the situation and harm the therapeutic relationship.
The nurse is caring for a dying client who has persistently requested that the nurse 'help her to die and be in peace.' According to the Code of Ethics for Nurses, the nurse should:
- A. Ask the client whether she has signed the advance directives document.
- B. Tell the client that he or she will ask another nurse to care for her.
- C. Instruct the client that only a physician can legally assist in suicide.
- D. Try to make the client as comfortable as possible, but refuse to assist in death.
Correct Answer: D
Rationale: The correct answer is to try to make the client as comfortable as possible but refuse to assist in death. According to the Code of Ethics for Nurses, nurses are committed to providing compassionate care, respecting the dignity and rights of the dying person. In this situation, it is important for the nurse to focus on providing comfort and support to the client while upholding ethical standards. Choice A is incorrect because discussing advance directives does not address the immediate request for assistance in dying. Choice B is incorrect as it does not address the ethical dilemma presented. Choice C is incorrect because instructing the client that only a physician can assist in suicide does not fully address the complexity of the situation or the nurse's role in providing end-of-life care.
Why is the intravenous route potentially the most dangerous route of drug administration?
- A. IV infiltration may occur.
- B. it allows for rapid administration of a drug.
- C. rapid administration of a drug can lead to toxicity
- D. it is the most commonly used route in hospitals.
Correct Answer: C
Rationale: The correct answer is C: rapid administration of a drug can lead to toxicity. When a drug is administered intravenously, it has 100% bioavailability, entering the bloodstream immediately and increasing the risk of toxicity if not carefully monitored. While IV infiltration (choice A) can cause tissue damage, it is not typically life-threatening. Choice B is incorrect as the speed of administration is not the primary reason for the danger; it is the immediate and full dose reaching the bloodstream. Choice D is incorrect as the popularity of the route does not inherently make it more dangerous.
An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals and cloudiness in the IV medication?
- A. Discard the solution and order a new bag
- B. Warm the solution
- C. Continue the infusion and document the finding
- D. Discontinue the medication
Correct Answer: A
Rationale: Crystals in the solution are not normal and should not be administered to the client. Discarding the solution and ordering a new bag is the correct action to ensure the client's safety. Warming the solution, as suggested in answer B, will not resolve the issue of crystals and cloudiness, which could potentially harm the client. Continuing the infusion, as in answer C, could pose a risk to the client due to the presence of abnormal substances. Answer D, discontinuing the medication, would typically require a doctor's order and should be done after discarding the contaminated solution.
Before administering Theodur to a 10-year-old being treated for asthma, the nurse should check the:
- A. Urinary output
- B. Blood pressure
- C. Pulse
- D. Temperature
Correct Answer: C
Rationale: The correct answer is to check the pulse. Theodur is a bronchodilator used in asthma treatment, and one of the side effects is tachycardia (increased heart rate). Therefore, it is essential to assess the pulse rate before administering Theodur to monitor for any potential tachycardia. Checking urinary output (Choice A), blood pressure (Choice B), and temperature (Choice D) are not directly related to the immediate side effects of bronchodilators like Theodur in this context, making them unnecessary assessments.