Nokea
A neurological consult has been ordered for a pediatric client with suspected absence seizures. The client with absence seizures can be expected to have:
- A. Short, abrupt muscle contractions
- B. Quick, severe bilateral jerking movements
- C. Abrupt loss of muscle tone
- D. Brief lapse in consciousness
Correct Answer: D
Rationale: Absence seizures cause brief lapses in consciousness, often appearing as staring spells, without motor symptoms.
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The nurse is teaching a client with a new diagnosis of heart failure about sodium restriction. Which of the following foods should the client avoid?
- A. Fresh apples.
- B. Canned soups.
- C. Baked chicken.
- D. Brown rice.
Correct Answer: B
Rationale: canned soups are high in sodium, which should be limited in heart failure to prevent fluid retention
The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to exert an effect:
- A. In 5-10 minutes
- B. In 10-20 minutes
- C. In 30-60 minutes
- D. In 60-120 minutes
Correct Answer: C
Rationale: Regular insulin has an onset of 30-60 minutes when given subcutaneously.
The physician has ordered cortisporin ear drops for a 2-year-old. To administer the ear drops, the nurse should:
- A. Pull the ear down and back
- B. Pull the ear straight out
- C. Pull the ear up and back
- D. Leave the ear undisturbed
Correct Answer: A
Rationale: For children under 3, pulling the ear down and back straightens the ear canal for proper administration of ear drops.
The nurse is caring for a client who was admitted to the burn unit 4 hours after the injury with second-degree burns to the trunk and head. Which finding would the nurse least expect to find during this time period?
- A. Hypovolemia
- B. Laryngeal edema
- C. Hypernatremia
- D. Hyperkalemia
Correct Answer: C
Rationale: Hypernatremia is least expected within 4 hours of a burn injury, as fluid shifts typically cause hyponatremia due to third-spacing. Hypovolemia, laryngeal edema, and hyperkalemia are common early findings.
A client has ataxia following a cerebral vascular accident. The nurse should:
- A. Supervise the client's ambulation
- B. Measure the client's intake and output
- C. Request a consult for speech therapy
- D. Provide the client with a magic slate
Correct Answer: A
Rationale: Ataxia impairs coordination, increasing fall risk, so supervising ambulation is essential for safety.