Nokea
A mother brings her two-year-old boy to the pediatrician’s office.
- A. Which symptom would suggest to the nurse that a two-year-old boy has strabismus?
- B. When the child draws, he places his head close to the table.
- C. The child rubs his eyes frequently.
- D. The child closes one eye to see a poster on the wall.
- E. The child is unable to see objects in the periphery of his visual field.
Correct Answer: C
Rationale: Strabismus is characterized by misaligned visual axes, causing the brain to receive two images. Closing one eye to focus on an object, such as a poster, is a compensatory behavior indicative of strabismus. The other symptoms suggest refractive errors or other visual impairments, not strabismus.
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A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child?
- A. Cartoon stickers
- B. Large wooden puzzle
- C. Blunt scissors and paper
- D. Beach ball
Correct Answer: B
Rationale: Large wooden puzzle. This is age-appropriate, supporting fine motor skills and cognitive development.
The nurse is caring for a client with a history of polycystic kidney disease.
- A. Which symptom is expected in a client with polycystic kidney disease?
- B. Chest pain and dyspnea.
- C. Flank pain and hematuria.
- D. Weight loss and fever.
- E. Numbness in the extremities.
Correct Answer: B
Rationale: Flank pain and hematuria are common in polycystic kidney disease due to cyst pressure and rupture. Chest pain, weight loss, and numbness are unrelated.
When caring for an abused client, what is most important for the nurse to do initially?
- A. Provide a safe place for the victim
- B. Refer the victim to a long-term support group
- C. Make an appointment with a counselor
- D. Make arrangements for the victim to confront the abuser
Correct Answer: A
Rationale: Providing a safe place is the priority, ensuring immediate protection from further abuse before addressing long-term support.
A postoperative client has pain medication ordered PRN for discomfort. During the first assessment, the nurse notes that the client has not received pain medication all day. His vital signs are within normal limits, but he is sweating profusely. He smiles at you while speaking and states that he is not hot but is still experiencing some pain and has been since early this morning. What is the most appropriate nursing action?
- A. Administer the largest dose of pain medication allowed because he has been without it all day and then allow him to rest undisturbed.
- B. Administer the minimum dose of medication and reassess his level of pain 30 minutes after administration.
- C. Hold the pain medication because his vital signs are within normal limits and he is smiling and showing no evidence of being in pain.
- D. Encourage the client to continue to do without pain medication so he won't become addicted to the opioid.
Correct Answer: B
Rationale: Administering the minimum dose and reassessing ensures effective pain management while monitoring response, given diaphoresis and reported pain.
A patient 48 hours after surgery for a hernia repair.
The nurse checks the incision of a patient 48 hours after surgery for a hernia repair. Which of the following findings would indicate a possible complication?
- A. There is swelling under the sutures.
- B. There is crusting around the incision line.
- C. The incision line is red.
- D. The incision line is approximated.
Correct Answer: C
Rationale: Strategy: Determine the significance of each answer choice. (1) slight swelling is expected during healing (2) slight crusting of incision line is normal (3) correct-should be pink, not red, indicates possible infection, other signs include increased warmth, tenderness, pain, and purulent or odorous drainage (4) shows healing is taking place