Nokea
In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust?
- A. Food
- B. Warmth
- C. Security
- D. Comfort
Correct Answer: C
Rationale: Security. Providing consistent, loving care fosters trust, a key developmental need for infants per Erikson's theory.
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The nurse is teaching a client with a new diagnosis of Parkinson’s disease about levodopa-carbidopa (Sinemet). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication on an empty stomach.
- B. I should avoid high-protein meals with this medication.
- C. I should report any muscle twitching to my doctor.
- D. I should expect my urine to turn dark.
Correct Answer: D
Rationale: Dark urine is not an expected side effect of levodopa-carbidopa; it may indicate another issue, such as hematuria, requiring investigation. Options A, B, and C are correct: taking on an empty stomach improves absorption, high-protein meals interfere with efficacy, and muscle twitching may indicate toxicity.
The nurse is administering digoxin to a 6-month-old infant. Which finding would cause the nurse to withhold the medication and notify the charge nurse or the physician?
- A. Apical heart rate of 85
- B. Appears lethargic
- C. Circumoral cyanosis
- D. Respiratory rate of 38
Correct Answer: A
Rationale: An apical heart rate below 100 in infants indicates bradycardia, a contraindication for digoxin due to toxicity risk, requiring withholding and reporting.
The nurse is caring for clients in the outpatient clinic. A young adult female is seeking help for weight loss. Her weight is 257 pounds, and she is 5'7'' tall.
Which of the following indicates the MOST appropriate diet choices for breakfast?
- A. Applesauce, cream of wheat, toast.
- B. Scrambled eggs and toast, one slice of bacon.
- C. One glass of grapefruit juice.
- D. Bagel with two ounces of cream cheese and a banana.
Correct Answer: A
Rationale: Strategy: Determine the topic of the question. (1) correct-breakfast with some substance won't leave her feeling hungry most of the morning (2) high fat content (3) doesn't provide a balance of nutrients and may leave the client feeling very hungry before lunch (4) high fat content
The nurse is teaching a client with a new diagnosis of gout about colchicine. Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any diarrhea.
- C. Stop the medication if gout attacks cease.
- D. Avoid regular joint exams.
Correct Answer: B
Rationale: Diarrhea is a serious colchicine side effect, indicating potential toxicity. Options A, C, and D are incorrect.
The nurse is caring for a client on complete bed rest. Which action by the nurse is most important in preventing the formation of deep vein thrombosis?
- A. Elevate the foot of the bed
- B. Apply knee high support stockings
- C. Encourage passive exercises
- D. Prevent pressure at back of knees
Correct Answer: D
Rationale: Preventing popliteal pressure will prevent venous stasis and possibly deep vein thrombosis.