Nokea
By the age of 7 months, the infant is able to do all the following EXCEPT
- A. transfer object from hand to hand
- B. actively bounces
- C. uses radial palm grasp
- D. roll over
Correct Answer: D
Rationale: Rolling over is usually achieved earlier, by 4-6 months, while other skills are typical for 7 months.
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Which of the ff is an initial sign or symptom of acute bronchitis?
- A. Nonproductive cough
- B. Anorexia
- C. Labored breathing
- D. Gastric ulceration
Correct Answer: A
Rationale: An initial sign or symptom of acute bronchitis is a nonproductive cough. This type of cough produces little to no phlegm or sputum. As the condition progresses, the cough may become productive, with the production of thick yellow or green mucus. Other common symptoms of acute bronchitis may include chest discomfort, fatigue, mild fever, and sore throat. Labored breathing is more commonly associated with conditions such as pneumonia or asthma, while anorexia and gastric ulceration are not typically initial signs of acute bronchitis.
A client has undergone a nephrectomy and is placed under observation after a urethral catheter insertion. As part of the nursing care plan, the nurse records the color of drainage from each tube and catheter. Which of the ff is the reason for this?
- A. To restore and maintain intravascular volume
- B. To provide a means for further comparison and evaluation
- C. To avoid interference with wound drainage
- D. To prevent pain related to obstruction
Correct Answer: B
Rationale: Recording the color of drainage from each tube and catheter is crucial in the nursing care plan as it provides a means for further comparison and evaluation. Changes in the color of drainage can indicate potential issues such as infection, bleeding, or other complications post-surgery. By monitoring the color of drainage, the nurse can identify any abnormal changes early on and take appropriate actions to address them promptly. This practice helps in assessing the patient's condition and ensuring optimal recovery and healing after the surgery.
The MOST likely cause of a 4-year-old boy refusing to go to bed and remaining active is
- A. thyrotoxicosis
- B. ADHD
- C. behavioral insomnia of childhood
- D. sleep-onset association disorder
Correct Answer: C
Rationale: Behavioral insomnia involves resistance to bedtime routines.
Nursing care for a patient who is experiencing a convulsive seizure includes all of the following except:
- A. Loosening constrictive clothing
- B. Opening the patient's jaw and inserting a mouth gag
- C. Positioning the patient on his or her side with head flexed forward
- D. Providing for privacy
Correct Answer: B
Rationale: Opening the patient's jaw and inserting a mouth gag is not part of the appropriate nursing care for a patient experiencing a convulsive seizure. Doing so can potentially harm the patient by causing injury to the teeth, jaw, or airway. It is important to protect the patient's airway during a seizure, but this can be done by positioning the patient on their side with the head flexed forward, ensuring a clear airway without the need for a mouth gag.
Mr. Reyea has expressive aphasia. As a part of a long range planning. The nurse should ;
- A. Provide positive feedback when he uses the word correctly
- B. Wait for him to verbally state needs regardless of how long it may take
- C. Suggest that he get help at home because the disability is permanent
- D. Help the family to accept the fact that Mr, Reyes cannot participate in verbal communication Situation - Patricia Zeno is a client with history myasthenia gravis
Correct Answer: A
Rationale: In caring for a patient with expressive aphasia like Mr. Reyea, providing positive feedback when he uses a word correctly is essential for reinforcing and encouraging communication efforts. This positive reinforcement can help boost his confidence and motivation to continue trying to communicate effectively. It is important to support and acknowledge any progress made, as communication difficulties can be frustrating for individuals with aphasia. Waiting for him to verbally state needs regardless of how long it may take, as well as suggesting that he get help at home because the disability is permanent, may not be the most therapeutic or supportive approaches. Helping the family accept that Mr. Reyea cannot participate in verbal communication should not be the primary focus, as there are strategies and therapies that can help improve communication abilities in patients with aphasia.