Nokea
A nurse is caring for a 10 year-old boy who has just been diagnosed with a congenital heart defect. Which of the following clinical signs does not indicate CHF?
- A. Increased body weight
- B. Elevated heart rate
- C. Lower extremity edema
- D. Compulsive behavior
Correct Answer: D
Rationale: Compulsive behavior does not indicate CHF.
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The nurse is working the same shift two days in a row. On the first of these days, while caring for one assigned client, the client says, 'Will you promise me you will be my nurse tomorrow?' Which response is most appropriate.
- A. Yes, I promise you I will be your nurse during my shift tomorrow.'
- B. You will need to speak to my supervisor about this request.'
- C. While I cannot promise that I will be your nurse tomorrow, I can talk to the charge nurse about this request.'
- D. Because of confidentiality, I cannot discuss tomorrow's assignments with you.'
Correct Answer: C
Rationale: While the nurse should not make any promises to the client, they can attempt to accommodate this request by speaking with their supervisor.
Which of the following methods of contraception is able to reduce the transmission of HIV and other STDs?
- A. intrauterine device (IUD)
- B. Norplant
- C. oral contraceptives
- D. vaginal sponge
Correct Answer: D
Rationale: The vaginal sponge is a barrier method of contraception that, when used with foam or jelly contraception, reduces the transmission of HIV and other STDs as well as reducing the risk of pregnancy. IUDs, Norplant, and oral contraceptives can prevent pregnancy but not the transmission HIV and STDs. Clients using the contraceptive methods in Choices A, B, and C should be counseled to use a chemical or barrier contraceptive to decrease transmission of HIV or STDs.
The nurse teaching an obese client about nutritional needs and weight loss should include all of the following except:
- A. knowledge of food and food products
- B. development of a positive mental attitude
- C. adequate exercise
- D. starting a fast weight-loss diet
Correct Answer: D
Rationale: Fast weight-loss diets are unsustainable and potentially harmful. Education should focus on nutrition knowledge, positive mindset, and exercise for healthy, gradual weight loss.
The LPN notices a client with poor gait and balance. She is currently being treated for hypertension, but the nurse is concerned. What should the nurse do?
- A. Add this issue to the nursing care plan and have daily gait/balance training as an intervention.
- B. Do nothing as this has nothing to do with why the client was hospitalized.
- C. Speak with the attending physician about his concerns and request a referral for the client to go to the hospital gym.
- D. Speak with the attending physician about his concerns and request a referral to physical therapy.
Correct Answer: D
Rationale: Nurses need to be aware of clients' needs even if they do not pertain to the reason for hospitalization and treatment. It is important to advocate for clients and request referrals when concerns and/or issues arise during care.
The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine?
- A. 6
- B. 8
- C. 12
- D. 16
Correct Answer: C
Rationale: In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick guide to the number of teeth a child should have is as follows: Subtract the number 6 from the number of months in the age of the child. In this example, the child is 18 months old, so the formula is 18 - 6 = 12. An 18-month-old child should have approximately 12 teeth.