Nokea
In terms of fine motor development, what should the infant of 7 months be able to do?
- A. Transfer objects from one hand to the other and bang cubes on a table.
- B. Use thumb and index finger in crude pincer grasp and release an object at will.
- C. Hold a crayon between the fingers and make a mark on paper.
- D. Release cubes into a cup and build a tower of two blocks.
Correct Answer: A
Rationale: At 7 months old, infants are typically able to transfer objects from one hand to the other and bang cubes on a table. This demonstrates the development of their fine motor skills related to coordination, dexterity, and object manipulation. They are refining their hand-eye coordination and grasping abilities at this stage, preparing for more complex fine motor tasks in the future. The ability to purposefully transfer objects between hands and make intentional actions, like banging cubes on a table, shows the progression of their fine motor development at this age.
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. A client with a suspected left sided heart failure is scheduled to undergo a multigated acquisition scan. Which of the following actions is required before undergoing the test?
- A. Diuretics are administered
- B. Client should avoid fluid intake 6 hours
- C. Client is medicated to relieve cough before the test
- D. Client is administered analgesics
Correct Answer: C
Rationale: Before undergoing a multigated acquisition scan, a client with suspected left sided heart failure should be medicated to relieve cough. Coughing can disrupt the accuracy of the scan results by affecting the heart's movement and leading to motion artifacts. Therefore, it is essential to address any coughing issues before the test to ensure reliable and accurate imaging of the heart's function. The other options, such as administering diuretics, avoiding fluid intake, and administering analgesics, are not directly related to optimizing the imaging quality of the multigated acquisition scan for a client with suspected left sided heart failure.
The nurse is caring for a client who is receiving antibiotics to treat a gram-negative bacterial infection. Because antibiotics destroy the body's normal flora, the nurse must monitor the client for:
- A. Platelet dysfunction
- B. Stomatitis
- C. Oliguria and dysuria
- D. Diarrhea
Correct Answer: D
Rationale: When a client is receiving antibiotics to treat an infection, especially a gram-negative bacterial infection, the antibiotics may disrupt the balance of normal flora in the gastrointestinal tract. This disruption can lead to an overgrowth of pathogenic bacteria, resulting in diarrhea. Clostridium difficile-associated diarrhea is a common complication of antibiotic therapy due to the disruption of normal gut flora. Therefore, the nurse must monitor the client for signs and symptoms of diarrhea and intervene promptly to prevent complications such as dehydration and electrolyte imbalances. Platelet dysfunction, stomatitis, and oliguria/dysuria are not typically associated with the destruction of normal flora due to antibiotic therapy for a gram-negative bacterial infection.
Which of the following is an early sign of anemia?
- A. Palpitations
- B. Pallor
- C. Glossitis
- D. Weight loss
Correct Answer: B
Rationale: Pallor, or paleness of the skin, is an early sign of anemia. Anemia occurs when there is a decrease in the number of red blood cells or the amount of hemoglobin in the blood, resulting in reduced oxygen supply to the body's tissues. This lack of oxygen can cause the skin to appear pale due to decreased blood flow. Other common symptoms of anemia may include fatigue, weakness, shortness of breath, dizziness, and cold hands and feet. Palpitations, glossitis, and weight loss are not typically early signs of anemia.
During the nursing interview Toni minimizes her visual problems talks about remaining in school to attempt advanced degrees, requests information about full-time jobs in nursing and mentions her desire to have several more children. The nurse recognizes her emotional responses as being:
- A. An example of inappropriate euphoria characteristic of the disease process
- B. A reflection of coping mechanisms used to deal with the exacerbation of her illness
- C. Indicative of the remission phase of her chronic illness
- D. Realistic for her current level of physical functioning
Correct Answer: A
Rationale: Toni's response of minimizing her visual problems, talking about pursuing advanced degrees, asking about full-time job opportunities in nursing, and mentioning her desire to have more children despite her current health situation may suggest inappropriate euphoria characteristic of the disease process. Inappropriate euphoria can be a sign of an altered mental state that is not in line with the reality of the situation. It is important for healthcare providers to recognize such emotional responses as they may indicate underlying mental health issues or the need for further assessment and support.
The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
- A. Serum potassium level of 4.9mEq/L
- B. Temperature of 99.2F (37.3C)
- C. Serum sodium level of 135mEq/L
- D. Urine output of 20mL/hour
Correct Answer: D
Rationale: A low urine output of 20mL/hour shortly after kidney transplant surgery is a critical finding that must be reported to the physician immediately. Adequate urine output is essential to ensure proper kidney function and the body's ability to eliminate waste products and regulate electrolyte levels. A urine output of less than 30mL/hour is considered oliguria, which may indicate decreased kidney function or potential complications such as acute kidney injury. Therefore, prompt evaluation and intervention are necessary to prevent further kidney damage or complications in the client.