Nokea
A 9-month-old infant visits her pediatrician for a routine visit. A developmental assessment was initiated by the nurse. Which skill would cause the nurse to be concerned about the infant's developmental progression?
- A. She sits briefly alone with assistance.
- B. She creeps and crawls.
- C. She pulls herself to her feet with help.
- D. She stands while holding onto furniture.
Correct Answer: A
Rationale: The 9-month-old infant can sit alone for long periods. Sitting briefly alone with assistance at this age suggests a developmental delay, warranting further evaluation.
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The nurse is in the hallway and one of the visitors faints. The nurse should:
- A. Sit the victim up and lightly slap his face
- B. Elevate the victim's legs
- C. Apply a cool cloth to the victim's neck and forehead until he recovers
- D. Sit the victim up and place the head between the knees
Correct Answer: B
Rationale: Sitting the client up defeats the goal of re-establishing cerebral blood flow. Elevating the legs anatomically redirects blood flow to the cerebral area. This strategy is a nice general comfort measure after the victim has regained consciousness. This strategy is not as effective a strategy in helping the client to regain consciousness as elevating the legs.
When preparing insulin for IV administration, the nurse identifies which kind of insulin to use?
- A. NPH
- B. Human or pork
- C. Regular
- D. Long acting
Correct Answer: C
Rationale: (A, B, D) Intermediate-acting and long-acting preparations contain materials that increase length of absorption time from the subcutaneous tissues but cause the preparation to be cloudy and unsuitable for IV use. Human insulin must be given SC. Only regular insulin can be given IV.
A client is scheduled for a biologic heart valve replacement. The nurse is aware that the client will require:
- A. Lifelong anticoagulant therapy
- B. Valve replacement every two years
- C. Strict dental hygiene to prevent bacterial infection
- D. Use of electric razor instead of safety razor
Correct Answer: C
Rationale: Biologic (tissue) heart valves are prone to bacterial endocarditis. Strict dental hygiene prevents infections that could seed the valve. Lifelong anticoagulation is typically for mechanical valves and the other options are not specific to biologic valves.
A client was exhibiting signs of mania and was recently started on lithium carbonate. She has no known physical problems. A teaching plan for this client would include which of the following?
- A. Regular foods should be eaten, including those that contain salt, such as bacon, ham, V-8 juice, and tomato juice.
- B. Restrict fluids to 1000 mL/day.
- C. Restrict foods that contain salt or sodium.
- D. Discontinue the medication if nausea occurs.
Correct Answer: A
Rationale: This answer is correct. A balanced diet with adequate salt intake is necessary. This answer is incorrect. The client must drink six to eight full glasses of fluid per day (2000-3000 mL/day). This answer is incorrect. The client should be instructed to avoid fluctuations of sodium intake. Diet should be balanced, with an adequate salt intake. This answer is incorrect. Nausea is a frequent side effect that can be minimized with administration of drug with meals or after eating food.
A client with cancer is experiencing a common side effect of chemotherapy administration. Which laboratory assessment finding would cause the most concern?
- A. A sodium level of 50 mg/dL
- B. A blood glucose of 110 mg/dL
- C. A platelet count of 125,000/mm3
- D. A white cell count of 5,000/mm3
Correct Answer: A
Rationale: A sodium level of 50 mg/dL is impossible (likely a typo for 50 mEq/L, which is severely hyponatremic) and life-threatening, causing seizures. Glucose (B), platelets (C), and WBC (D) are near normal or less critical.