Nokea
In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant?
- A. Increased 10% in height
- B. 2 deciduous teeth
- C. Tripled the birth weight
- D. Head > chest circumference
Correct Answer: C
Rationale: Tripled the birth weight. Infants typically triple their birth weight by 12 months.
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A client with right-sided weakness.
The nurse in the outpatient clinic teaches a client with right-sided weakness to walk down stairs using a cane. What behavior, if demonstrated by the client, would indicate that teaching was successful?
- A. The client puts her right leg on the step, then the cane, followed by her left leg.
- B. The client leads with the cane, followed by her right leg, and then her left leg.
- C. The client advances her right leg, followed by her left leg and the cane.
- D. The client puts the cane on the step and advances her left leg, followed by her right leg.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) to go down stairs, advance weak leg and cane first; to go up stairs, advance strong leg, then weak leg and cane (2) correct-to do down stairs, advance cane and weak leg, then strong leg; memory trick: the good goes up, the bad goes down (3) should advance cane and weak leg first (4) weaker leg and cane advance first
The nurse is caring for a client with a history of glaucoma.
- A. Which instruction should the nurse include for a client with glaucoma using timolol eye drops?
- B. Apply pressure to the inner canthus after instillation.
- C. Administer the drops at bedtime only.
- D. Use the drops only when symptoms occur.
- E. Cleanse the eye with saline before instillation.
Correct Answer: A
Rationale: Applying pressure to the inner canthus (nasolacrimal occlusion) prevents systemic absorption of timolol, reducing side effects like bradycardia. Drops are used regularly, not symptom-based, and cleansing is unnecessary unless debris is present.
The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of congestive heart disease. Which other finding is most likely to occur?
- A. Chest pain
- B. Peripheral edema
- C. Nail clubbing
- D. Lethargy
Correct Answer: B
Rationale: Peripheral edema. Bibasilar crackles and peripheral edema are common in congestive heart failure due to fluid overload.
The nurse is teaching a client with a new diagnosis of hypertension about lifestyle modifications. Which of the following statements by the client indicates a need for further teaching?
- A. I should exercise for 30 minutes most days.
- B. I should reduce my salt intake.
- C. I should avoid smoking.
- D. I should limit my coffee to one cup a day.
Correct Answer: D
Rationale: Limiting coffee to one cup a day is unnecessary, as moderate caffeine does not significantly affect blood pressure in most hypertensive patients. Options A, B, and C are correct: exercise, low-sodium diet, and smoking cessation reduce blood pressure.
A 13 year old girl is admitted to the ER with lower right abdominal discomfort. The admitting nursing should take which the following measures first?
- A. Administer Loritab to the patient for pain relief.
- B. Place the patient in right sidelying position for pressure relief.
- C. Start a Central Line.
- D. Provide pain reduction techniques without administering medication.
Correct Answer: D
Rationale: Do not administer pain medication or start a central line without MD orders.