Nokea
The mother of a 24-month-old child tells the nurse that she is concerned that her child's language abilities are delayed. Which of the following language milestones does the nurse expect the child to exhibit?
- A. Understands 300 words and uses two- and three-word sentences.
- B. Says and understands a few words, such as 'Mama' and 'Dada,' and can imitate animal sounds, such as 'moo' and 'woof.'
- C. Says and understands four to six words but understands more and can point to items he wants.
- D. Says and understands up to 20 words and can point to his body parts.
Correct Answer: A
Rationale: A 24-month-old should understand about 300 words and use two- to three-word sentences (A). Other options (B, C, D) describe earlier developmental stages.
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The nurse caring for a client with chest tubes notes that the Pleuravac's collection chambers are full. The nurse should:
- A. Add more water to the suction-control chamber
- B. Remove the drainage using a 60 mL syringe
- C. Milk the tubing to facilitate drainage
- D. Prepare a new unit for continuing collection
Correct Answer: D
Rationale: When the Pleuravac collection chambers are full, a new unit is needed to continue effective drainage and maintain the closed system.
The client with color blindness will most likely have problems distinguishing which of the following colors?
- A. Orange
- B. Violet
- C. Red
- D. White
Correct Answer: C
Rationale: Red-green color blindness is the most common type, making it difficult to distinguish red.
A client prescribed furosemide (Lasix) should choose which meal for lunch?
- A. chicken breast, white rice, apple
- B. turkey sandwich on wheat bread, celery sticks, grapefruit
- C. egg salad, cooked carrots, strawberries
- D. baked salmon, spinach salad, banana
Correct Answer: D
Rationale: Furosemide causes potassium loss. A meal with potassium-rich foods (e.g., spinach, banana) helps maintain electrolyte balance.
An obstetrical client with diabetes has an amniocentesis at 28 weeks gestation. Which test indicates the degree of fetal lung maturity?
- A. Alpha-fetoprotein
- B. Estriol level
- C. Indirect Coomb's
- D. Lecithin sphingomyelin ratio
Correct Answer: D
Rationale: The lecithin-sphingomyelin (L/S) ratio assesses fetal lung maturity by measuring surfactant levels, critical for preterm delivery planning in diabetic pregnancies.
The nurse is providing dietary instructions for a client with iron-deficiency anemia. Which food is a poor source of iron?
- A. Tomatoes
- B. Legumes
- C. Dried fruits
- D. Nuts
Correct Answer: A
Rationale: Tomatoes are a poor source of iron compared to legumes, dried fruits, and nuts, which are rich in iron and recommended for iron-deficiency anemia.