Nokea
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.
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The nurse has a client who is being transferred to another floor right around change of shift. Which of the following actions is least appropriate?
- A. Inform the staff on the other floor of any unresolved issues with the client.
- B. Ask the charge nurse if overtime would be permitted to complete the client's transfer to the other floor.
- C. Ask the new nurse to take care of the transfer since the client's medical record has all of the information and a report should not be needed.
- D. Complete the transfer paperwork before the client is transferred.
Correct Answer: C
Rationale: The nurse should ensure a safe handoff of care during the transfer. The nurse on the next shift should not be asked to complete the transfer for the client without a full handoff of care.
Referral for client education in the community can be accomplished through all of the following except:
- A. community agencies such as the American Heart Association.
- B. parish nurses.
- C. home health care agencies.
- D. unlicensed massage therapists.
Correct Answer: D
Rationale: Client education should be completed by an individual or individuals with acknowledged expertise in the subject area and credentials to support activity within the health care community.
Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?
- A. administering immune globulin intravenously
- B. assessing the extremities for edema, redness and desquamation every 8 hours
- C. explaining progression of the disease to the client and his or her family
- D. assessing heart sounds and rhythm
Correct Answer: C
Rationale: Teaching the client and family about progression of the disease includes explaining when symptoms can be expected to improve and resolve. Knowledge of the course of the disease can help them understand that no permanent disruption in physical appearance will occur that could negatively affect body image. Clients with Kawasaki disease might receive immune globulin intravenously to reduce the incidence of coronary artery lesions and aneurysms. Cardiac effects could be linked to body image, but Choice 3 is the most direct link to body image. The nurse assesses symptoms to assist in evaluation of treatment and progression of the disease.
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.
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.