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A nurse is reinforcing teaching about toilet training with the guardians of a toddler who has a cognitive impairment. Which of the following instructions should the nurse include?
- A. Encourage the toddler to flush the toilet while still seated.
- B. Have the toddler remain on the toilet for a minimum of 20 min.
- C. Wake the toddler every 2 hr. in the night to prevent bed-wetting.
- D. Give the toddler a sticker after each successful toileting attempt.
Correct Answer: D
Rationale: Giving the toddler a sticker after each successful toileting attempt is correct. Positive reinforcement, such as stickers or praise, encourages consistency and motivation, which is particularly beneficial for children with cognitive impairments.
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A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following findings should indicate to the nurse that the client is developing a thyroid storm?
- A. Decreased body temperature
- B. Increased incisional drainage
- C. Hypertension
- D. Bradycardia
Correct Answer: C
Rationale: Hypertension is correct. Thyroid storm is a severe, acute exacerbation of hyperthyroidism, and it is associated with hypertension, tachycardia, fever, and other symptoms of sympathetic nervous system overactivity.
A nurse is caring for a client who has a new prescription for montelukast. Which of the following adverse effects should the nurse monitor for?
- A. Mood changes
- B. Weight loss
- C. Bradycardia
- D. Hypoglycemia
Correct Answer: A
Rationale: Montelukast, a leukotriene inhibitor, can cause mood changes, including anxiety or depression, which require monitoring.
A nurse is collecting data from a client who is at 32 weeks of gestation and is experiencing preterm labor. Which of the following findings should the nurse expect?
- A. The client reports a tightening of her abdomen.
- B. The client reports increased urinary output.
- C. The client reports a temperature of 38.9°C (102°F).
- D. The client reports seeing bright red blood.
Correct Answer: A
Rationale: A tightening of the abdomen indicates uterine contractions, a hallmark of preterm labor, which the nurse should expect at 32 weeks of gestation.
A nurse is caring for a client who has a new diagnosis of fibromyalgia. Which of the following findings should the nurse expect?
- A. Chronic pain
- B. Weight loss
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Chronic pain, often widespread, is a hallmark symptom of fibromyalgia affecting muscles and joints.
A nurse is caring for a client who has a new prescription for heparin. Which of the following laboratory values should the nurse monitor?
- A. Platelet count
- B. Blood urea nitrogen
- C. Serum albumin
- D. Cholesterol
Correct Answer: A
Rationale: Heparin can cause thrombocytopenia, so monitoring platelet count is essential to detect potential bleeding risks.