Nokea
A nurse is caring for a 2-year-old with a new diagnosis of strabismus. Which intervention should the nurse anticipate?
- A. Correction with laser surgery
- B. Eye drops in the affected eye
- C. Measurement of intraocular pressure
- D. Patching of the unaffected eye
Correct Answer: D
Rationale: Patching the unaffected eye strengthens the weaker eye in strabismus by forcing its use, a common non-surgical treatment in children. Laser surgery is not typically used, eye drops are irrelevant, and intraocular pressure measurement is for glaucoma, not strabismus.
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The nurse monitors a client who has followed a vegan diet for several years. Which client statement would indicate a possible complication resulting from a vegan diet?
- A. I have had some visual disturbances while driving at night.
- B. I have had trouble falling asleep over the past few months.
- C. Scaly patches of skin are developing on my elbows and knees.
- D. Sometimes my hands and feet get a tingling sensation.
Correct Answer: A
Rationale: Night vision disturbances suggest vitamin A deficiency, common in vegan diets lacking sufficient beta-carotene sources. Insomnia, scaly skin, and tingling are less specific to vegan diet complications, potentially relating to other causes like stress or neuropathy.
As part of a routine health screening, the nurse notes the play of a 2-year-old child. Which of the following is an example of age-appropriate play at this age?
- A. builds towers with several blocks
- B. tries to color within the lines
- C. says 'Mine!' when playing with toys
- D. tries to jump rope
Correct Answer: C
Rationale: Saying 'Mine!' reflects the possessive, independent behavior typical of 2-year-olds. The other activities are either too advanced or not age-specific. Health Promotion and Maintenance
The nurse is preparing to administer 40 mg of oral furosemide. Prior to administering the medication, the nurse should evaluate which parameters? Select all that apply.
- A. Blood pressure
- B. Blood urea nitrogen
- C. Liver enzymes
- D. Potassium
- E. White blood cell count
Correct Answer: A,D
Rationale: Furosemide can cause hypotension and hypokalemia, so blood pressure and potassium levels must be evaluated. Blood urea nitrogen reflects kidney function but is not critical before administration, and liver enzymes and white blood cell count are unrelated.
In an emergency situation, the nurse determines whether a client has an airway obstruction. Which of the following does the nurse assess?
- A. ability to speak
- B. ability to hear
- C. oxygen saturation
- D. adventitious breath sounds
Correct Answer: A
Rationale: Inability to speak is a primary indicator of airway obstruction, as it suggests blocked airflow. Hearing, oxygen saturation, and breath sounds are secondary or less immediate. Safety and Infection Control
The most suitable diet for the client with Meniere's disease is:
- A. High in animal protein
- B. Restricted in sodium
- C. High in fat-soluble vitamins
- D. Restricted in complex carbohydrates
Correct Answer: B
Rationale: A low sodium diet and nicotinic acid have been shown to be effective in reducing the symptoms of Meniere's disease. Answers A, C, and D are incorrect because they do not relieve the symptoms of Meniere's disease.