Nokea
The age of a child who imitates construction of a bridge of 3 cubes; copies circle; makes tower of 10 cubes is
- A. 24 months old
- B. 30 months old
- C. 36 months old
- D. 42 months old
Correct Answer: C
Rationale: These milestones are typically achieved around 36 months.
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Which of the following elements shows that the client does not understand the cause of exacerbation of system lupus erythematosus (SLE)?
- A. "I don't have to worry about changing my
- B. "I don't have to worry if I get a strep. throat diet."
- C. I need to work on managing stress in life."
Correct Answer: B
Rationale: Option B, "I don't have to worry if I get a strep throat," shows that the client does not understand the cause of exacerbation of systemic lupus erythematosus (SLE). Strep throat can trigger SLE exacerbations as infections are known to worsen autoimmune diseases like lupus. This statement indicates a lack of awareness regarding the potential impact of infections on SLE symptoms. Option A and C show a better understanding as they address the importance of diet and stress management, which are significant factors that can influence the course of SLE.
An 83-year old client diagnosed with COPD has been receiving 1L of oxygen via nasal cannula. When the relatives visited, the sister of the client increased the oxygen to 7L per minute because she says that the client "looks like he is having difficulty getting air." What should the nurse's initial action be?
- A. Thank the client's sister and continue to observe the client
- B. Immediately decrease the oxygen
- C. Notify the physician
- D. elevate client's head and take her vital signs
Correct Answer: C
Rationale: Increasing the oxygen flow rate from 1L to 7L per minute without a healthcare provider's order is not safe for the client. High-flow oxygen can lead to oxygen toxicity, absorption atelectasis, and can reduce the respiratory drive in patients with COPD. The nurse's initial action should be to notify the physician about the change in oxygen delivery and the client's condition. The physician should reevaluate the client's oxygen requirements and provide appropriate orders based on the clinical assessment. It is crucial to follow evidence-based guidelines and healthcare provider orders for oxygen administration to ensure patient safety and optimal outcomes.
Several hours after returning from surgery, the nurse tells the patient that she is ordered to be ambulated. The patient asks, "Why?" Which of the following complications would the nurse correctly explain can be prevented by early postoperative ambulation?
- A. Increased peristalsis
- B. Coughing
- C. Pneumonia
- D. Wound healing  A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET K
Correct Answer: C
Rationale: Early postoperative ambulation is important for preventing complications such as pneumonia. When a patient remains immobile for an extended period after surgery, they are at an increased risk of developing pneumonia due to decreased lung expansion and secretions pooling in the lungs. Ambulation helps improve lung function, promote better oxygenation, and prevent respiratory complications like pneumonia. In contrast, increased peristalsis helps prevent constipation, coughing helps prevent respiratory complications as well, and wound healing is not directly related to the need for early postoperative ambulation.
Mr. Aurelio diagnosed with heart failure, was prescribed with a 2 gm sodium diet. which of the following foods would nurse Norma instruct him to restrict?
- A. whole wheat bread
- B. canned tomato juice
- C. beef tenderloin strips
- D. apples
Correct Answer: B
Rationale: Canned tomato juice is often high in sodium content due to added salt during processing. Since Mr. Aurelio has been prescribed a 2 gm sodium diet, the nurse would instruct him to restrict foods high in sodium content, such as canned tomato juice. Whole wheat bread and apples are generally low in sodium, and beef tenderloin strips can be chosen in lean cuts and prepared without high sodium additives, making them more suitable for Mr. Aurelio's dietary restrictions.
The nurse should expect to assess which causative agent in a child with warts?
- A. Bacteria
- B. Fungus
- C. Parasite
- D. Virus
Correct Answer: D
Rationale: Warts are typically caused by a viral infection, specifically the human papillomavirus (HPV). This virus infects the top layer of the skin, causing the skin cells to grow rapidly, leading to the formation of a wart. Other causative agents such as bacteria, fungus, and parasites do not typically cause warts in children. Therefore, when assessing a child with warts, the nurse should expect the causative agent to be a virus, specifically HPV.