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During the first 72 hours post CVA, the nurse should position the client:
- A. Supine
- B. Semi-Fowler
- C. Left Sim's
- D. Prone
Correct Answer: B
Rationale: Semi-Fowler's position (30-45 degrees) reduces intracranial pressure and promotes venous drainage in the acute phase post-stroke.
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According to Erickson's stage of growth and development, the developmental task associated with middle childhood is:
- A. Trust
- B. Initiative
- C. Independence
- D. Industry
Correct Answer: D
Rationale: Middle childhood (ages 6-12) is associated with the developmental task of industry, where children focus on competence and achievement.
The nurse is caring for a client with a history of meningitis.
- A. Which precaution is most appropriate for a client with bacterial meningitis?
- B. Standard precautions.
- C. Droplet precautions.
- D. Contact precautions.
- E. Airborne precautions.
Correct Answer: B
Rationale: Droplet precautions are required for bacterial meningitis (e.g., Neisseria meningitidis) to prevent transmission via respiratory secretions. Standard precautions are insufficient, and contact or airborne precautions are incorrect.
The nurse is caring for a client with a history of peptic ulcer disease who is receiving ranitidine (Zantac) 150 mg PO bid. Which of the following symptoms should the nurse report immediately?
- A. Mild epigastric discomfort.
- B. Occasional heartburn.
- C. Black, tarry stools.
- D. Nausea after meals.
Correct Answer: C
Rationale: Black, tarry stools indicate gastroinTest inal bleeding, a serious complication in peptic ulcer disease. Options A, B, and D are less urgent.
The provisions of the law for the Americans with Disabilities Act require nurse managers to
- A. Maintain an environment free from associated hazards
- B. Provide reasonable accommodations for disabled individuals
- C. Make all necessary accommodations for disabled individuals
- D. Consider both mental and physical disabilities
Correct Answer: B
Rationale: The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant's ability to perform the job and not discriminate on the basis of a disability. Employers also must make 'reasonable accommodations.'
The nurse's neighbor complains to the nurse that he feels tired all the time. Which comment suggests to the nurse that the man may have a serious sleep disorder?
- A. My wife complains because I snore off and on all night.'
- B. I like to nap in the afternoon.'
- C. I wake up early every morning.'
- D. My muscles seem to jerk as I fall asleep.'
Correct Answer: A
Rationale: Snoring may indicate sleep apnea, a serious disorder causing fatigue, unlike napping, early waking, or muscle jerks, which are less concerning.