Nokea
A nurse is instructing a patient about the warning signs of (Digitalis) side effects. Which of the following side effects should the nurse tell the patient are sometimes associated with excessive levels of Digitalis?
- A. Seizures
- B. Muscle weakness
- C. Depression
- D. Anxiety
Correct Answer: B
Rationale: Palpitations and muscle weakness are found with excessive levels of Digitalis, as they are signs of toxicity.
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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: Toddlers are possessive and struggle for independence. The other play activities are too advanced for a 2-year-old child.
Which of these clients should the LPN/LVN see first?
- A. a client with a newly placed NG who is complaining of pain around the face and a plugged nose
- B. a post-op prostatectomy client who complains of bladder spasms and blood in his foley bag
- C. a client in an arm cast who is 2 days post-op and reports feelings of numbness and tingling in her affected arm
- D. a client newly diagnosed with Hepatitis A who reports stomach pain and itchy skin
Correct Answer: C
Rationale: Numbness and tingling hours or days after a cast is applied may indicate compartment syndrome and should be reported to a medical provider right away. The other options all feature expected or typical symptoms related to their diagnosis.
When choosing a needle gauge for an intramuscular injection in a 12 year old boy. Which of the following gauges would you choose?
- A. 27 gauge
- B. 25 gauge
- C. 22 gauge
- D. 20 gauge
Correct Answer: C
Rationale: 22 gauge is recommended for school age children, toddlers, and adolescents while 23-25 gauge is recommended for infants.
When a client who is having trouble conceiving says to the nurse, 'I have started taking ginseng,' the best response by the nurse is:
- A. No studies show that ginseng is effective for infertility.'
- B. Some studies show that ginseng enhances in vitro sperm motility.'
- C. Why don't you try acupuncture instead. Many studies have shown it to be effective for infertility.'
- D. It's probably not going to hurt you, but it's also probably not going to help. Let's look at some other alternatives.'
Correct Answer: B
Rationale: Acknowledging studies suggesting ginseng may enhance sperm motility validates the client's efforts while fostering open discussion about fertility options.
A client is having an abortion in a women's clinic and the nurse caring for the client does not think the reasoning is appropriate. The nurse asks, 'Are you sure you want to do this, it can't be undone. Have you read about your other options? Adoption is always a good choice.' The client states she understands all options and is comfortable with her choice. The nurse nods and leaves the room to discuss the procedure with the physician. Which client right did the nurse violate with her actions?
- A. the client's right to make personal health decisions without interference, as the nurse tried to sway the client's decision-making and healthcare choice in the direction of not having an abortion
- B. the client's right to be left alone without unsolicited attention, as the nurse inserted herself in the client's healthcare scenario and offered uninvited advice
- C. the client's right to confidentiality, as the nurse is talking to the physician about the client and the abortion
- D. the client's right to respectful care, as the nurse clearly made it known that she did not approve of the abortion
Correct Answer: A
Rationale: A client has the right to make decisions about his or her healthcare without interference from health team members. It is our duty to respect those decisions and not try to influence patients based on our beliefs.