Nokea
A mother frantically calls the emergency room (ER) asking what to do about her 3-year-old girl who was found eating pills out of a bottle in the medicine cabinet. The ER nurse tells the mother to:
- A. Give the child 15 mL of syrup of ipecac.
- B. Give the child 10 mL of syrup of ipecac with a sip of water.
- C. Give the child 1 cup of water to induce vomiting.
- D. Bring the child to the ER immediately.
Correct Answer: D
Rationale: Before giving any emetic, the substance ingested must be known. At least 8 oz of water should be administered along with ipecac syrup to increase volume in the stomach and facilitate vomiting. Water alone will not induce vomiting. An emetic is necessary to facilitate vomiting. Vomiting should never be induced in an unconscious client because of the risk of aspiration.
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The nurse is caring for a client with a diagnosis of oligohydramnios. Which finding is most likely to be present?
- A. Decreased fetal movement
- B. Increased fetal heart rate
- C. Uterine size larger than expected
- D. Fetal macrosomia
Correct Answer: A
Rationale: Oligohydramnios (low amniotic fluid) can restrict fetal movement due to limited space making decreased fetal movement a likely finding. Fetal heart rate may be normal or show distress uterine size is smaller and macrosomia is unrelated.
The nurse is caring for a client with a diagnosis of gestational hypertension. Which intervention is most appropriate?
- A. Monitor blood pressure
- B. Administer antihypertensives
- C. Monitor fetal heart tones
- D. All of the above
Correct Answer: D
Rationale: Gestational hypertension requires blood pressure monitoring to assess severity antihypertensives for severe hypertension and fetal heart tone monitoring to ensure fetal well-being. All interventions are appropriate.
Because a client is taking an MAO inhibitor, it is necessary to discuss the need for adherence to a low-tyramine diet. Which of the following are foods that she should avoid?
- A. Pickled, aged, smoked, and fermented foods
- B. Fresh vegetables
- C. Broiled fresh fish and fowl
- D. Fresh fruit such as apples and oranges
Correct Answer: A
Rationale: These foods may produce elevation in blood pressure when consumed during MAO inhibition therapy. These foods have not been pickled, fermented, smoked, or aged. They contain very little, if any, tyramine or tryptophan. As long as the meat has not been aged or smoked, it is within the dietary regimen. Fresh fruits can be consumed as desired. However, the consumption of bananas is limited.
The nurse is caring for a client with a cerebrovascular accident (CVA) who is complaining of being nauseated and is requesting an emesis basin. Which action would the nurse take first?
- A. Administer an ordered antiemetic.
- B. Obtain an ice bag and apply to the client's throat.
- C. Turn the client to one side.
- D. Notify the physician.
Correct Answer: C
Rationale: Turning the client to one side prevents aspiration, a priority in a nauseated CVA client with potential swallowing deficits. Administering an antiemetic (A) or notifying the physician (D) is secondary, and ice (B) is ineffective.
Which of the following describes the language development of a two-year-old?
- A. Doesn't understand yes and no
- B. Understands the meaning of all words
- C. Can combine three or four words
- D. Repeatedly asks 'why?'
Correct Answer: C
Rationale: A two-year-old typically can combine three or four words to form simple sentences (e.g., 'Me want milk'). They understand basic concepts like 'yes' and 'no,' but not all words. Repeatedly asking 'why?' is more common in older preschoolers.