Nokea
Signs of impaired breathing in infants and children include all of the following except:
- A. nasal flaring.
- B. grunting.
- C. seesaw breathing.
- D. quivering lips.
Correct Answer: D
Rationale: Nasal flaring, grunting, and seesaw breathing are signs of respiratory distress in infants and children. Quivering lips are not a recognized indicator of impaired breathing. Physiological Adaptation
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The wife of a man who is comatose following a head injury asks the nurse if she should visit him since he is unresponsive. How should the nurse reply initially?
- A. Explain that since he is unresponsive there is no need for her to be here
- B. Tell her that the nurse will call if there is any change
- C. Suggest that her presence is important even though he seems unaware
- D. Recommend that she ask his coworkers to visit
Correct Answer: C
Rationale: Presence of loved ones may provide comfort and stimulate awareness in comatose patients, supporting family involvement. Other responses discourage visitation.
The nurse is assessing a client with a history of migraines. Which of the following symptoms would the nurse expect the client to report?
- A. Bilateral dull headache.
- B. Photophobia and nausea.
- C. Constant daily headache.
- D. Pain relieved by physical activity.
Correct Answer: B
Rationale: Migraines typically cause unilateral throbbing pain with photophobia and nausea due to neurological sensitivity. Bilateral dull pain (A) suggests tension headache, constant pain (C) indicates chronic headache, and activity (D) worsens migraines.
The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered
- A. Expected
- B. Rude
- C. Professional
- D. Enjoyable
Correct Answer: B
Rationale: Rude. Native Americans consider direct eye contact to be impolite or aggressive among strangers.
A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding the most significant?
- A. Decreased level of consciousness (LOC)
- B. Elevated blood pressure
- C. Increased urine output
- D. Decreased heart rate
Correct Answer: C
Rationale: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.
A nurse is caring for a patient with diabetes mellitus who is scheduled for surgery. Which of the following is the most important preoperative assessment?
- A. Blood glucose level.
- B. Electrolyte levels.
- C. Complete blood count (CBC).
- D. Urinalysis.
Correct Answer: A
Rationale: Blood glucose control is critical preoperatively in diabetes to prevent complications like wound infections or ketoacidosis. Electrolytes, CBC, and urinalysis are important but secondary, as glucose directly impacts surgical outcomes.