Nokea
The nurse anticipates that for a family who practices Chinese medicine the priority therapeutic goal would be to
- A. achieve harmony
- B. maintain a balance of energy
- C. respect life
- D. restore yin and yang
Correct Answer: D
Rationale: For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang.
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The nurse is preparing to discharge a client with a new diagnosis of asthma.
- A. What is the most important teaching point for a client with a new asthma diagnosis?
- B. Use a spacer with the metered-dose inhaler.
- C. Take the bronchodilator before the corticosteroid.
- D. Avoid exercise to prevent asthma attacks.
- E. Monitor peak flow readings daily.
Correct Answer: D
Rationale: Daily peak flow monitoring helps the client detect early changes in lung function, enabling timely intervention to prevent asthma exacerbations. Using a spacer, proper medication sequencing, and exercise management are important but secondary to ongoing monitoring.
A mother brings her two-year-old boy to the pediatrician’s office.
- A. Which symptom would suggest to the nurse that a two-year-old boy has strabismus?
- B. When the child draws, he places his head close to the table.
- C. The child rubs his eyes frequently.
- D. The child closes one eye to see a poster on the wall.
- E. The child is unable to see objects in the periphery of his visual field.
Correct Answer: C
Rationale: Strabismus is characterized by misaligned visual axes, causing the brain to receive two images. Closing one eye to focus on an object, such as a poster, is a compensatory behavior indicative of strabismus. The other symptoms suggest refractive errors or other visual impairments, not strabismus.
An 85-year-old client with diverticulitis has been vomiting and febrile for 12 hours. Where is the best location to assess skin turgor on this client?
- A. Dorsal hand
- B. Feet
- C. Back of the arm
- D. Sternum
Correct Answer: D
Rationale: This is the best area to check in the elderly due to loss of skin elasticity that occurs with aging. Answers A, B, and C are all influenced by loss of elasticity more than the sternum, so they are incorrect.
A baby is delivered following a pregnancy complicated by gestational diabetes. What should the nurse observe the baby for?
- A. Infection
- B. Hyperglycemia
- C. Acidosis
- D. Hypoglycemia
Correct Answer: D
Rationale: Infants of mothers with gestational diabetes are at risk for hypoglycemia due to high fetal insulin levels from maternal hyperglycemia, requiring close monitoring.
The nurse is caring for clients in the prenatal clinic. The nurse would be MOST concerned if a diabetic client in the third trimester makes which of the following statements?
- A. I am taking less insulin now than I did two months ago.
- B. I am eating a large bedtime snack.
- C. I walk 15 minutes after lunch every day.
- D. I check my blood sugar two hours after each meal.
Correct Answer: A
Rationale: Decreased insulin needs in the third trimester suggest placental dysfunction, as placental hormones typically increase insulin resistance. Options B, C, and D are appropriate: bedtime snacks prevent hypoglycemia, exercise after meals manages glucose, and postprandial checks monitor hyperglycemia.