Nokea
At what age should the nurse expect an infant to begin smiling in response to pleasurable stimuli?
- A. 1 month
- B. 2 months
- C. 3 months
- D. 4 months
Correct Answer: B
Rationale: Infants typically begin to smile in response to pleasurable stimuli around 2 months of age. This social smile is an important developmental milestone in infants and signifies their growing social awareness and ability to engage with others. By the age of 2 months, infants are starting to develop social connections and recognize familiar faces, which often elicits smiles in response to positive interactions. Though some infants may start smiling earlier or later, the average age for the emergence of social smiles is around 2 months.
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A Jewish client has been diagnosed with ulcerative colitis. A nursing diagnosis appropriate for a client who has ulcerative colitis is:
- A. abdominal pain related to decreased peristalsis
- B. diarrhea related to hyperosmolar intestinal contents
- C. fluid volume excess related to increase water absorption by intestinal mucosa
- D. activity intolerance related to fatigue
Correct Answer: A
Rationale: Among the given choices, the nursing diagnosis appropriate for a client with ulcerative colitis is "abdominal pain related to decreased peristalsis." Ulcerative colitis is a chronic inflammatory bowel disease that directly affects the lining of the colon and rectum, leading to symptoms such as abdominal pain, diarrhea, and bloody stool. Decreased peristalsis occurs in patients with ulcerative colitis, resulting in abdominal pain due to inflammation and irritation of the intestines. This pain is a common symptom experienced by individuals with ulcerative colitis and can significantly impact their quality of life. Therefore, addressing the client's abdominal pain is crucial in providing effective nursing care for someone diagnosed with ulcerative colitis.
Kim is using bronchodilators for asthma. The side effects of these drugs that you need to monitor this patient for include:
- A. tachycardia, nausea, vomiting, heart palpitations, inability to sleep, restlessness, and seizures.
- B. tachycardia, headache, dyspnea, temp. 101 F, and wheezing.
- C. blurred vision, tachycardia, hypertension, headache, insomnia, and oliguria.
- D. restlessness, insomnia, blurred vision, hypertension, chest pain, and muscleweakness.
Correct Answer: A
Rationale: Bronchodilators are medications used to relax and open the airways in the lungs, making it easier to breathe for patients with conditions like asthma. Common side effects of bronchodilators that need to be monitored in patients include tachycardia (increased heart rate), nausea, vomiting, heart palpitations, inability to sleep, restlessness, and in severe cases, seizures. These side effects can vary depending on the type of bronchodilator being used, but it is important for healthcare providers to monitor patients for these symptoms and adjust their treatment as needed.
The following data collection findings could indicate to the nurse that the patient has a hearing loss, EXCEPT:
- A. Patient's face is relaxed during conversation.
- B. Patient speaks in a very loud voice.
- C. Patient turns toward person speaking.
- D. Patient is withdrawn.
Correct Answer: A
Rationale: A relaxed face during conversation is not typically indicative of hearing loss. In fact, individuals with hearing loss may exhibit signs such as speaking loudly (Choice B), turning toward the person speaking (Choice C), and feeling withdrawn (Choice D) due to difficulty in hearing and understanding conversations. The act of speaking loudly may be an attempt to compensate for the perceived hearing loss, while turning toward the speaker is a common strategy to better hear and lip-read. Withdrawal can result from the frustration and isolation caused by the inability to fully engage in conversations. Ultimately, a relaxed face during conversation is less likely to be a red flag for hearing loss compared to the other choices provided.
Autism screening is recommended for all children at age of
- A. 12 to 18 months
- B. 18 to 24 months
- C. 24 to 36 months
- D. 36 to 48 months
Correct Answer: B
Rationale: Autism screening is recommended between 18 and 24 months.
A client with a history of cardiac dysrhythmias is admitted to the hospital with the diagnosis of dehydration. The nurse should anticipate that the physician will order;
- A. A glass of water every hour until hydrated
- B. Small frequent intake of juices, broth, or milk
- C. Short-term NG replacement of fluids and nutrients
- D. A rapid IV infusion of an electrolyte and glucose solution
Correct Answer: D
Rationale: A client with a history of cardiac dysrhythmias and dehydration requires careful monitoring and management of fluid and electrolyte balance. The most appropriate intervention for rapid correction of dehydration in this scenario is a rapid IV infusion of an electrolyte and glucose solution. This method allows for the quick replacement of fluids and essential electrolytes to restore the client's hydration status efficiently and effectively. Administering fluids orally may not be adequate in this situation, and NG replacement of fluids and nutrients may not be necessary if the client's condition can be managed through IV therapy. Therefore, option D is the most appropriate choice for this client.