Nokea
A nurse is teaching a class for new parents at a local community center. The nurse would stress that what is most hazardous for an 8 month-old child?
- A. Riding in a car
- B. Falling off a bed
- C. An electrical outlet
- D. Eating peanuts
Correct Answer: D
Rationale: Eating peanuts. Asphyxiation due to foreign materials in the respiratory tract is the leading cause of death in children younger than 6 years of age.
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An elderly client has a 17-mm induration after a tuberculin skin test. Based on this result, which statement is most accurate?
- A. The client has a false-positive reaction due to advanced age
- B. The client has a tuberculosis infection
- C. The client has active tuberculosis disease
- D. The client must be isolated immediately
Correct Answer: B
Rationale: A 17-mm induration in an elderly client indicates TB infection, as the threshold is ≥10 mm for high-risk groups. It doesn't confirm active disease, which requires further testing (e.g., chest X-ray). False positives are possible but not assumed based on age alone. Isolation isn't required without active disease.
The family of a frail elderly man who is bedridden asks the nurse what they can do to prevent bedsores. Which response by the nurse is best?
- A. Get him out of bed at least once a day.'
- B. Turn him every two hours.'
- C. Rub his buttocks and apply lotion several times a day.'
- D. Change the sheets every day.'
Correct Answer: B
Rationale: Turning every two hours relieves pressure on bony prominences, preventing pressure ulcers. Getting out of bed may be infeasible, and rubbing or sheet changes are less effective.
The nurse is caring for a client who has a pulmonary embolism. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. dyspnea
- B. chest pain
- C. tachypnea
- D. hypoxemia
- E. bradycardia
- F. tracheal deviation
Correct Answer: A,B,C,D
Rationale: Pulmonary embolism obstructs pulmonary arteries, causing dyspnea, chest pain, tachypnea, and hypoxemia. Bradycardia is unlikely; tachycardia is typical. Tracheal deviation is associated with tension pneumothorax, not embolism.
A client with schizophrenia is ready to begin participating in therapeutic activities. The nurse should suggest that the client:
- A. Participate on the unit softball team
- B. Attend a class on psychotropic medication
- C. Participate in art activities with three other clients
- D. Watch TV in the unit day room
Correct Answer: C
Rationale: Art activities with a small group provide a structured, low-stress environment suitable for a client with schizophrenia, promoting social interaction without overwhelming them.
Which client would be at greatest risk for a fat emboli following a fracture?
- A. A 50-year-old with a fractured fibula
- B. A 20-year-old female with a wrist fracture
- C. A 21-year-old male with a fractured femur
- D. An 8-year-old with a fractured arm
Correct Answer: C
Rationale: Fat emboli occur more frequently with long bone or pelvic fractures and usually in young adults age 20-30. Answers A, B, and D are not high-risk incidents and do not fall in the greater risk category, so they are incorrect.