Nokea
During a home visit, the nurse is evaluating an infant for auditory ability. Which of the following is the expected response in an infant with normal hearing?
- A. Stoppage of body movements when sound is introduced.
- B. Evidence of shy and withdrawn behaviors.
- C. Saying 'da-da' by age 5 months.
- D. Absence of squealing by age 4 months.
Correct Answer: A
Rationale: Infants with normal hearing typically pause or stop movements in response to sound, indicating auditory awareness.
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The nurse is assessing a client with suspected hypovolemic shock. Which finding is most indicative?
- A. Tachycardia
- B. Hypertension
- C. Warm, dry skin
- D. Bradypnea
Correct Answer: A
Rationale: Tachycardia is an early sign of hypovolemic shock as the body compensates for reduced blood volume by increasing heart rate.
A client with a diagnosis of hyperthyroidism is prescribed methimazole (Tapazole). The nurse should monitor the client for which of the following side effects?
- A. Weight gain.
- B. Agranulocytosis.
- C. Hypertension.
- D. Hyperglycemia.
Correct Answer: B
Rationale: Methimazole can cause agranulocytosis, requiring monitoring of white blood cell counts.
A client with a history of duodenal ulcer is taking calcium carbonate chewable tablets. The nurse monitors the client for relief of which symptom?
- A. Flatus
- B. Heartburn
- C. Rectal pain
- D. Muscle twitching
Correct Answer: B
Rationale: Calcium carbonate is used as an antacid for the relief of heartburn and indigestion. It can also be used as a calcium supplement or to bind phosphorus in the gastrointestinal tract in clients with renal failure. The remaining options are unrelated to this medication.
A nurse who fails to check a client's armband before administering his medications is:
- A. Negligent.
- B. Following standard procedure.
- C. Acting within their scope of practice.
- D. Exercising professional judgment.
Correct Answer: A
Rationale: Failing to check a client's armband before administering medications is negligent, as it violates patient safety protocols for verifying identity.
A client with a history of chronic heart failure is prescribed digoxin (Lanoxin). The nurse should monitor the client for which of the following signs of toxicity? Select all that apply.
- A. Nausea.
- B. Visual disturbances.
- C. Tachycardia.
- D. Fatigue.
- E. Hypokalemia.
Correct Answer: A, B, D
Rationale: Digoxin toxicity presents with nausea, visual disturbances (e.g., yellow vision), and fatigue. Hypokalemia increases toxicity risk but is not a symptom.