Nokea
An elderly client has been noted to have increasing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing:
- A. Proprioception
- B. Agnosia
- C. Sundowning
- D. Confabulation
Correct Answer: C
Rationale: Sundowning is increased confusion or agitation in the late afternoon or evening common in elderly patients with dementia. Proprioception agnosia and confabulation do not describe this time-specific behavior.
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The nurse would teach a male JOB client ways to minimize the risk of infection after eye surgery. Which of the following indicates the client needs further teaching?
- A. I will wash my hands before instilling eye medications.'
- B. I will wear sunglasses when going outside.'
- C. I will wear an eye patch for the first 3 postoperative days.'
- D. I will maintain the sterility of the eye medications.'
Correct Answer: C
Rationale: Eye patches are typically worn during sleep or naps, not constantly for 3 days, indicating a need for further teaching. The other options are correct preventive measures.
Which term describes the play activity of the preschool aged child?
- A. Cooperative
- B. Associative
- C. Parallel
- D. Solitary
Correct Answer: B
Rationale: Preschool-aged children (3–5 years) typically engage in associative play, where they play together with shared activities but without formal rules or organization. Cooperative play develops later, parallel play is common in toddlers, and solitary play is seen in younger children.
A client is admitted to the labor and delivery unit in active labor. The physician performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?
- A. Fetal heart tones 160 bpm
- B. Moderate uterine contractions
- C. A large amount of straw-colored fluid
- D. Thick green amniotic fluid
Correct Answer: C
Rationale: After an amniotomy the nurse expects to observe a large amount of clear or straw-colored amniotic fluid indicating normal amniotic fluid. Fetal heart tones of 160 bpm are normal but not specific to amniotomy contractions are unrelated and green fluid suggests meconium which is abnormal.
Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the rationale for this therapy is to:
- A. Remove the potassium from the body by renin exchange
- B. Protect the myocardium from the effects of hypokalemia
- C. Promote rapid protein catabolism
- D. Drive potassium from the serum back into the cells
Correct Answer: D
Rationale: Sodium polystyrene sulfonate (Kayexalate), a cation exchange resin, exchanges sodium ions for potassium ions in the large intestine reducing the serum potassium. Calcium is administered to protect the myocardium from the adverse effects of hyperkalemia. Serum levels reflect hyperkalemia. Rapid catabolism releases potassium from the body tissue into the bloodstream. Infection and hyperthermia increase the process of catabolism. The administration of dextrose and regular insulin IV forces potassium back into the cells decreasing the potassium in the serum.
A 4-week-old infant is admitted to the emergency room in respiratory distress. Which of the following statements indicates the nurse's knowledge of the anatomy of the respiratory system in pediatric clients?
- A. The diameter of the trachea is much smaller in children than in adults.
- B. The tongue is proportionally smaller in children than in adults.
- C. The pediatric airway is more rigid than that of the adults.
- D. The length of the pediatric airway is longer in children than in adults.
Correct Answer: A
Rationale: The airway in children is much smaller than it is in adults. The diameter of the trachea in the newborn is 4 mm and that of the adult is 20 mm. A small change in the diameter of the airway can make a major difference in the pediatric client. The tongue is proportionally larger in children and fills most of the oral cavity, thereby decreasing air space. The entire pediatric airway is elastic. Elasticity diminishes with age, however. The distances between respiratory structures are shorter than that of adults, and therefore organisms are able to move more rapidly down the throat, leading to more extensive respiratory involvement.