Nokea
The father of an 8 month-old infant asks the nurse if his child's vocalizations are normal for his age. Which of the following would the nurse expect at this age?
- A. Cooing
- B. Imitation of sounds
- C. Throaty sounds
- D. Laughter
Correct Answer: B
Rationale: Imitation of sounds. Eight-month-olds typically imitate sounds like 'da-da' as part of language development.
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Laboratory reference ranges
Hematocrit
Male: 42%-52%
(0.42-0.52)
Female: 37%-47%
(0.37-0.47)
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)
Female: 12-16 g/dL
(120-160 g/L)
The nurse is reviewing the chart of a client who has a traumatic below-the-knee amputation. Which client should the nurse see first?
- A. Female client who had an arthroscopic rotator cuff repair with sling immobilization and reports moderate swelling and tingling of the hand and fingers
- B. Female client who has a new cast and reports stinging of the hand and fingers and inability to move the toes
- C. Male client who has two new prosthetic legs applied after traumatic below-the-knee amputation and reports crushing pain in the amputated areas
- D. Male client who has a hematocrit of 37% (0.37) and hemoglobin of 12.5 g/dL (125 g/L) and is prescribed enoxaparin 1 day after a total hip arthroplasty
Correct Answer: A
Rationale: Stinging and inability to move toes in a new cast suggest compartment syndrome, a surgical emergency. Phantom limb pain and normal hematocrit/enoxaparin are less urgent.
The nurse talking with a client with polycythemia vera. Which of the following statements by the client would require follow-up?
- A. I will drink plenty of water every day
- B. I should take a low-dose aspirin every day
- C. I need to have blood removed periodically
- D. I will continue taking my daily multivitamin with iron
Correct Answer: D
Rationale: Iron supplements can worsen polycythemia vera by increasing red blood cell production. Hydration, aspirin, and phlebotomy are appropriate management strategies.
The nurse is reinforcing teaching about nutrition with the parents of a 6-year-old client with cystic fibrosis. Which recommended diet should the nurse include?
- A. High calorie, high protein
- B. High carbohydrate, low fiber
- C. Low fat, low sodium
- D. Low phosphate, low protein
Correct Answer: A
Rationale: Cystic fibrosis requires a high-calorie, high-protein diet to support growth and compensate for malabsorption. Other diets do not meet the increased nutritional demands.
The nurse is to administer a tuberculin skin test. At what angle should the needle be inserted?
- A. A 10-degree angle
- B. A 30-degree angle
- C. A 60-degree angle
- D. A 90-degree angle
Correct Answer: A
Rationale: A 10-degree angle ensures intradermal injection for a tuberculin skin test, creating a wheal for accurate reading.
Following a motor vehicle accident, the client does not know where he is or what year it is and has short-term memory impairment. Which nursing action is most appropriate?
- A. Offer several choices to the client.
- B. Give simple directions to the client.
- C. Give the client the details of the care.
- D. Offer written instructions to the client.
Correct Answer: B
Rationale: Simple directions accommodate memory impairment and disorientation, enhancing comprehension and safety post-accident.