Nokea
The clinic nurse is interviewing the parents of a 6-month-old client about the infant's diet. Which statement by the parents is most concerning?
- A. Because apples are healthy, we make apple pie and feed small, soft bites to our baby.
- B. If our baby refuses to finish foods, we continue to offer small bites, so food isn't wasted.
- C. Infant oatmeal sweetened with fresh honey is our baby's favorite breakfast.
- D. We found that the food in TV dinners can be easily pureed and is convenient.
Correct Answer: C
Rationale: Honey poses a botulism risk in infants under 1 year, making it the most concerning. Apple pie and TV dinners are inappropriate but less dangerous, and offering bites is not harmful.
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The nurse reinforces discharge teaching for the parent of a child newly prescribed methylphenidate for attention-deficit hyperactivity disorder. The nurse advises the parent that the child might experience which side effects?
- A. Decreased blood pressure and growth delays
- B. Heart palpitations and weight gain
- C. Loss of appetite and restlessness
- D. Trouble sleeping and a dry cough
Correct Answer: C
Rationale: Methylphenidate commonly causes loss of appetite and restlessness . Hypotension , palpitations/weight gain , and cough are less typical.
The client presents to the unit with complaints of shortness of breath. A tentative diagnosis of respiratory acidosis related to pneumonia is made. Which finding would support this diagnosis?
- A. $\mathrm{pH}$ of $7.45, \mathrm{CO}_2$ of $45, \mathrm{HCO}_3$ of 26
- B. $\mathrm{pH}$ of $7.35, \mathrm{CO}_2$ of $46, \mathrm{HCO}_3$ of 27
- C. $\mathrm{pH}$ of $7.34, \mathrm{CO}_2$ of $30, \mathrm{HCO}_3$ of 22
- D. $\mathrm{pH}$ of $7.44, \mathrm{CO}_2$ of $32, \mathrm{HCO}_3$ of 25
Correct Answer: B
Rationale: Respiratory acidosis is characterized by a low pH (<7.35) and elevated CO₂ (>45 mmHg) due to impaired gas exchange, as in pneumonia. Option B (pH 7.35, CO₂ 46, HCO₃ 27) is closest to this profile, with slight compensation. Options A, C, and D show normal or alkalotic pH or low CO₂.
A nurse at outpatient clinic is returning phone calls that have been made to the clinic. Which of the following calls should have the highest priority for medical intervention?
- A. A home health patient reports, 'I am starting to have breakdown of my heels.'
- B. A patient that received an upper extremity cast yesterday reports, 'I can't feel my fingers in my right hand today.'
- C. A young female reports, 'I think I sprained my ankle about 2 weeks ago.'
- D. A middle-aged patient reports, 'My knee is still hurting from the TKR.'
Correct Answer: B
Rationale: The patient experiencing neurovascular changes should have the highest priority. Pain following a TKR is normal, and breakdown over the heels is a gradual process. Moreover, a subacute ankle sprain is almost never a medical emergency.
Which of the following nursing assessment findings require immediate discontinuance of an antipsychotic medication?
- A. Involuntary rhythmic stereotypic movements and tongue protrusion
- B. Cheek puffing, involuntary movements of extremities and trunk
- C. Agitation, constant state of motion
- D. Hyperpyrexia, severe muscle rigidity, malignant hypertension
Correct Answer: D
Rationale: Hyperpyrexia, severe muscle rigidity, and malignant hypertension are signs of neuroleptic malignant syndrome (NMS), requiring immediate discontinuation of the antipsychotic.
Which of the following beverages is most appropriate for a client with renal failure?
- A. Prune juice
- B. Grape juice
- C. Apple juice
- D. Apricot juice
Correct Answer: C
Rationale: Apple juice is most appropriate for a client with renalrape juice has a lower potassium content, which is crucial for renal failure patients who need to limit potassium intake. Prune, grape, and apricot juices are high in potassium, which can be harmful in renal failure.