Nokea
The guardian of a 4-year-old child.
A nurse is collecting a health history from the guardian of a 4-year-old child. Which of the following statements by the guardian is the priority for the nurse to address?
- A. I have noticed that my child is withdrawn since we switched day care providers.
- B. My child continually asks me the same questions.
- C. My child still wets the bed at least two times per week.
- D. I have a difficult time getting my child to eat green vegetables.
Correct Answer: A
Rationale: Withdrawal may indicate emotional distress, a priority over typical developmental behaviors.
You may also like to solve these questions
A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?
- A. Offer the client several choices at mealtimes.
- B. Alternate daily caregivers.
- C. Avoid discussing the client's fears.
- D. Remind the client of the day and time often.
Correct Answer: D
Rationale: Frequent orientation to time reduces confusion in delirium.
The client is in renal failure.
A nurse is collecting data from a client who is in renal failure. Which of the following findings should the nurse identify as a manifestation of hyperkalemia?
- A. Dry mucous membranes
- B. Hyperactive reflexes
- C. Trousseau's sign
- D. Irregular heart rate
Correct Answer: D
Rationale: Irregular heart rate is a hallmark of hyperkalemia due to its effect on cardiac conduction.
The client is dependent on nicotine and wishes to discontinue smoking.
A nurse is reinforcing teaching with a client who is dependent on nicotine and wishes to discontinue smoking. The nurse should inform the client that which of the following is a manifestation of nicotine withdrawal?
- A. Weight loss
- B. Diaphoresis
- C. Insomnia
- D. Diarrhea
Correct Answer: C
Rationale: Insomnia is a common nicotine withdrawal symptom.
A nurse is collecting data from a client who is 1 day postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider?
- A. Dark red urine
- B. Urine output of 300 mL over 8 hr
- C. Occasional small clots in the urine
- D. Frequent urge to urinate
Correct Answer: A
Rationale: Dark red urine suggests significant bleeding, requiring immediate reporting.
A nurse is reinforcing teaching about the side effects of metoprolol. Which of the following client statements indicates an understanding of the teaching?
- A. I need to be careful when standing up from bed.
- B. I should limit my intake of leafy green vegetables.
- C. I should expect some weight loss.
- D. I may experience loss of taste.
Correct Answer: A
Rationale: Metoprolol can cause orthostatic hypotension, requiring caution when standing.