Nokea
A preschooler has successfully completed the test item 'counts 5 blocks' on the Denver II test. This pass is evidence of which of the following developmental concepts?
- A. centration
- B. causality
- C. nonreversibility
- D. conservation
Correct Answer: D
Rationale: The ability of a preschooler to move five blocks to a piece of paper and state there are five blocks on the paper is evidence that the preschooler has the ability of conservation. This concept refers to the fact that the quantity of something doesn't change just because the shape, contour, and so on has changed. Five blocks are still five blocks, whether they are lying beside the paper, stacked on the paper, or moved to the paper. Centration is the ability to concentrate on one feature of a situation while neglecting all other aspects. Causality is based on the sequence of events, one event ordinarily following another. Non-reversibility refers to the inability of preschoolers to reverse their operations. They are only able to think forward, not retrace or reverse their thought processes.
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While taking the vital signs of a pregnant client admitted to the labor unit, a nurse notes a temperature of 100.6°F, pulse rate of 100 beats/min, and respirations of 24 breaths/min. What is the most appropriate nursing action based on these findings?
- A. Notify the registered nurse of the findings.
- B. Document the findings in the client's medical record.
- C. Recheck the vital signs in 1 hour.
- D. Continue collecting subjective and objective data.
Correct Answer: A
Rationale: The correct answer is to notify the registered nurse of the findings. In a pregnant client, the normal temperature range is 98°F to 99.6°F, with a pulse rate of 60 to 90 beats/min and respirations of 12 to 20 breaths/min. A temperature of 100.4°F or higher, along with an increased pulse rate and faster respirations, suggests a possible infection. Immediate notification of the registered nurse is crucial for further evaluation and intervention. While documenting the findings is essential, the priority lies in promptly escalating abnormal vital signs for assessment and management. Rechecking vital signs in 1 hour may delay necessary interventions for a deteriorating condition. Continuing to collect data is relevant but should not delay informing the registered nurse when abnormal vital signs are present.
A nurse is administering an antibiotic to a 4 year old girl, who does not have an identification bracelet. What action should the nurse take?
- A. Ask another staff member who the child is.
- B. Ask the child's mother to state the child's name.
- C. Ask the child for her name.
- D. Withhold the medication until an ID bracelet can be set-up.
Correct Answer: B
Rationale: Timely delivery of medication can be given if the mother provides the child's name. Do not rely on children to identify their name correctly.
When a client describes their family as having multiple wives, all of whom are sisters, married to one man, the nurse documents the family structure as?
- A. polyandry
- B. soronal
- C. nonsororal
- D. sororate
Correct Answer: B
Rationale: The practice of polygamy refers to having multiple wives or husbands. When there are multiple wives who are sisters, the polygamy is designated as soronal. When the wives are not sisters it is nonsororal. Polyandry refers to multiple husbands and is rare. Some cultures practice a polygamy designated as sororate. Sororate polygamy specifies that a husband must marry his wife's sister if she dies. These marriages are successive rather than concurrent.
A client has a 10 % dextrose in water IV solution running. He is scheduled to receive his antiepileptic drug, phenytoin (Dilantin), at this time. The nurse knows that the phenytoin:
- A. is given after the D10W is finished.
- B. should be given at the time it is due in the medication port closest to the client.
- C. can be piggybacked into the D10W solution now.
- D. is incompatible with dext SAMEple solutions.
Correct Answer: D
Rationale: Phenytoin and dextrose will precipitate. Normal saline is used to flush before and after phenytoin administration. The administration of an antiepileptic drug cannot be delayed to maintain a therapeutic blood level.
A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths/min. On the basis of this finding, what is the most appropriate action for the nurse to take?
- A. Contacting the registered nurse
- B. Documenting the findings
- C. Wrapping an extra blanket around the infant
- D. Placing the infant in an oxygen tent
Correct Answer: B
Rationale: The normal respiratory rate of a newborn infant is 30 to 60 breaths/min, with an average of 40. Since the infant's respiratory rate falls within the normal range, the most appropriate action for the nurse is to document the findings. Contacting the registered nurse, placing the infant in an oxygen tent, or wrapping an extra blanket around the infant are unnecessary actions as the respiratory rate is normal. Documenting the findings is important to provide a record of the assessment and serve as a baseline for future comparisons if needed.