Nokea
Prior to discharge of a child with a ventriculoperitoneal (VP) shunt, the nurse reinforces teaching to the caregiver about when to contact the health care provider. The caregiver shows understanding of the instructions by contacting the health care provider about which symptom?
- A. A temperature of 98.6°F (37.2°C) that occurs during the evening
- B. The child cannot recall items eaten for lunch the previous day
- C. The child vomits after awakening from a nap and again 1 hour later
- D. The VP shunt is palpable along the posterolateral portion of the skull
Correct Answer: C
Rationale: Persistent vomiting (C) suggests shunt malfunction or increased intracranial pressure, requiring immediate reporting. Normal temperature (A), memory lapses (B), and palpable shunt (D) are not concerning.
You may also like to solve these questions
A young adult is admitted to the psychiatric unit because she has become very withdrawn and has stopped attending college classes. She sits for hours rocking back and forth and appears to be talking to someone at intervals. She does not eat or bathe or relate to others. How should the nurse approach this client upon admission?
- A. Explain the unit routines to her in detail
- B. Ask her if she has any question about the unit or what she is supposed to do
- C. Briefly explain the most essential information and then sit with her
- D. Take her by the hand and orient her to the unit
Correct Answer: C
Rationale: A withdrawn client may be overwhelmed by detailed explanations. Brief information and quiet presence build trust and reduce anxiety.
A low-residue diet is ordered for an adult. The nurse knows that the client understands the diet when which menu is selected?
- A. Lettuce and tomato salad, steak sandwich, orange slices
- B. Gelatin salad, mashed potatoes, sliced chicken
- C. Corn casserole, pork chop, rice
- D. Broccoli, broiled fish, sesame seed roll
Correct Answer: B
Rationale: Gelatin, mashed potatoes, and sliced chicken are low-fiber, low-residue foods, suitable for the diet. Lettuce, corn, broccoli, and sesame seeds are high-fiber, increasing residue.
Prior to administering a tube feeding, the nurse obtains 50 mL of aspirant. The nurse should:
- A. Discard the aspirant and begin the tube feeding.
- B. Replace the aspirant and begin the tube feeding.
- C. Discard the aspirant and hold the tube feeding.
- D. Replace the aspirant and hold the tube feeding.
Correct Answer: B
Rationale: Replacing the aspirant prevents fluid/electrolyte loss, and feeding can proceed if pH confirms placement. Discarding aspirant risks dehydration, and holding the feeding is unnecessary unless placement is uncertain.
The nurse is caring for four antepartum clients. Which client should the nurse see first?
- A. Client with hyperemesis gravidarum who is currently vomiting (9%)
- B. Client with molar pregnancy who has dark brown vaginal discharge (8%)
- C. Client with suspected ectopic pregnancy who has abdominal and shoulder pain (71%)
- D. Client with threatened miscarriage who says, 'I am a Jehovah's Witness.' (10%)
Correct Answer: C
Rationale: A suspected ectopic pregnancy is a medical emergency due to the risk of rupture and internal bleeding, which can be life-threatening. Abdominal and shoulder pain are hallmark symptoms, indicating possible referred pain from diaphragmatic irritation. This client requires immediate assessment and intervention, prioritizing over hyperemesis gravidarum (which, while serious, is less immediately life-threatening), molar pregnancy (which needs monitoring but is not an acute emergency), and threatened miscarriage (which requires evaluation but is less urgent without active bleeding or pain).
A client taking Zoloft (sertraline) tells the nurse that she has also been taking St. John's wort. The nurse should report this information to the doctor because:
- A. The two substances have opposing effects.
- B. The amount of medication may be reduced.
- C. Herbals only provide a placebo effect.
- D. It will be necessary to increase the dosage.
Correct Answer: B
Rationale: St. John's wort can induce the metabolism of Zoloft, potentially reducing its effectiveness, so the doctor may need to adjust the dose. Answer A is incorrect as they do not have opposing effects. Answer C is incorrect as St. John's wort has pharmacological effects. Answer D is incorrect as increasing the dose may not be necessary.