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: Pulling a toy is consistent with an 18-month-old's developmental level, supporting the assessment.
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Which would be included in the nursing care plan of a client experiencing severe delirium tremens?
- A. Placing the client in a darkened room
- B. Keeping the closet and bathroom doors closed
- C. Administering a diuretic to decrease fluid excess
- D. Checking vital signs every 8 hours
Correct Answer: B
Rationale: Keeping closet and bathroom doors closed minimizes visual stimuli that could exacerbate hallucinations or confusion in delirium tremens, promoting a safe environment.
The physician has prescribed Cognex (tacrine) for a client with dementia. The nurse should monitor the client for adverse reactions, which include:
- A. Hypoglycemia
- B. Jaundice
- C. Urinary retention
- D. Tinnitus
Correct Answer: B
Rationale: Tacrine (Cognex) is associated with hepatotoxicity, and jaundice is a sign of liver dysfunction that should be monitored.
The nurse is working on a neurological unit. If the following events occur simultaneously, which would receive RN priority?
- A. A client with a cerebral aneurysm complains of sudden weakness on the right side.
- B. A client with a suspected brain tumor complains of a headache.
- C. A client post-op lumbar laminectomy vomits.
- D. A client with Guillain-Barre syndrome has a temp of 99.6°F.
Correct Answer: A
Rationale: Sudden weakness in a client with a cerebral aneurysm suggests possible rupture or neurological deterioration, a life-threatening emergency requiring immediate attention.
The nurse is planning dietary changes for a client following an episode of acute pancreatitis. Which diet is suitable for the client?
- A. Low calorie, low carbohydrate
- B. High calorie, low fat
- C. High protein, high fat
- D. Low protein, high carbohydrate
Correct Answer: B
Rationale: A high-calorie, low-fat diet is suitable post-acute pancreatitis to support recovery while minimizing pancreatic stimulation.
The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time?
- A. Confirm that all staff members understand and comply with the treatment plan.
- B. Establish mutually agreed upon, realistic goals.
- C. Ensure that the potent reinforcers (rewards) are important to the client.
- D. Establish a fixed interval schedule for reinforcement.
Correct Answer: A
Rationale: to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program