Nokea
A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying 'no' and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?
- A. Trust
- B. Initiative
- C. Independence
- D. Self-esteem
Correct Answer: C
Rationale: Independence. In Erikson's theory of development, toddlers struggle to assert independence, often using the word 'no' to establish autonomy.
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The nurse is providing home care to a postoperative client who has a wound infection. What is essential to include when teaching the family about infection transmission?
- A. The client should stay isolated from the rest of the family.
- B. No one who is pregnant should care for the client.
- C. The family should wash hands before and after caring for the client.
- D. The client should not be allowed to have any visitors.
Correct Answer: C
Rationale: Hand washing before and after care is critical to prevent infection transmission. Isolation, restricting pregnant caregivers, or banning visitors are not necessary unless specified.
The nurse is caring for a client who is postoperative day 1 after a thyroidectomy. Which of the following actions is the PRIORITY?
- A. Monitor the client for neck swelling.
- B. Administer pain medication as needed.
- C. Encourage the client to cough and deep breathe.
- D. Check the incision for drainage.
Correct Answer: A
Rationale: Monitoring for neck swelling is the priority to detect hematoma, a life-threatening complication post-thyroidectomy that can cause airway obstruction. Options B, C, and D are important but secondary: pain management, respiratory exercises, and incision checks follow airway safety.
A client is placed on sulfamethoxazole-trimethoprim (Bactrim) for a recurrent urinary tract infection. Which of the following is appropriate reinforcement of information by the nurse?
- A. Drink at least 8 glasses of water a day.
- B. Be sure to take the medication with food.
- C. It is safe to take with oral contraceptives.
- D. Stop the medication after 5 days.
Correct Answer: A
Rationale: Bactrim is a highly insoluble drug and requires a large volume of fluid intake. It is not necessary to take it with food. Options C and D are incorrect instructions for those taking Bactrim.
Which of the following nursing actions has the HIGHEST priority in caring for the client with hypoparathyroidism?
- A. Develop a teaching plan.
- B. Plan measures to deal with cardiac dysrhythmias.
- C. Take measures to prevent a respiratory infection.
- D. Assess laboratory results.
Correct Answer: B
Rationale: cardiac dysrhythmias related to low serum calcium would be the highest priority
A client suspected to have bulimia.
Which of the following observations by the nurse would MOST likely indicate bulimia?
- A. The client has edema of the lower extremities.
- B. Physical exam of the client reveals the presence of lanugo.
- C. The client has ulcerated mucous membranes of the mouth.
- D. The client has dry, yellowish color of the skin.
Correct Answer: C
Rationale: Strategy: Determine the cause of each symptom. Does it relate to bulimia? (1) common with anorexia (2) seen with anorexia (3) correct-due to frequent vomiting (4) bulimics are normal in appearance