Nokea
The nurse assesses an 18-month-old child brought to the well child clinic for a routine check-up. Which finding would be of most concern to the nurse?
- A. The child can creep up stairs.
- B. The child is not toilet trained.
- C. The child drops objects handed to him.
- D. The child cries when his mother leaves him with a stranger.
Correct Answer: C
Rationale: Dropping objects handed to him suggests motor or neurological issues at 18 months, requiring evaluation. Creeping , not being toilet trained , and stranger anxiety are normal.
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The nurse is teaching parents of a 7 month-old about adding table foods. Which of the following is an appropriate finger food?
- A. Hot dog pieces
- B. Sliced bananas
- C. Whole grapes
- D. Popcorn
Correct Answer: B
Rationale: Sliced bananas. Finger foods should be bite-size pieces of soft food such as bananas. Hot dogs and grapes can accidentally be swallowed whole and-mile occlude the airway. Popcorn is too difficult to chew at this age and can irritate the airway if swallowed.
The family of a 48-year-old woman who has multiple sclerosis and spends most of her time in bed or in a chair asks the nurse why they have been told they should have her take deep breaths and cough frequently. What should the nurse include in the reply?
- A. Deep breathing and coughing will help her to move her secretions so she will not develop pneumonia.
- B. Deep breathing and coughing help to prevent clots from developing in the lung.
- C. When she coughs, she increases the amount of oxygen going to the brain, preventing confusion.
- D. Deep breathing increases blood flow to the brain and helps to keep her from getting depressed.
Correct Answer: A
Rationale: Immobility in multiple sclerosis increases pneumonia risk; deep breathing and coughing mobilize secretions, preventing respiratory infections.
A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse?
- A. Call a chaplain
- B. Deny the feelings
- C. Cite recovery statistics
- D. Listen to the client
Correct Answer: D
Rationale: Listen to the client. Therapeutic communications are based on attentive listening to expressed feelings, followed by questions about cultural beliefs if needed.
A 25-year-old man is in an acute manic episode. The nurse knows that which client behavior would be MOST characteristic of mania?
- A. Agitation, grandiose delusions, euphoria, difficulty concentrating.
- B. Difficulty in decision-making, preoccupation with self, distorted perceptions.
- C. Paranoia, hallucinations, disturbed thought processes, hypervigilance.
- D. Fear of going crazy, somatic complaints, difficulties with intimacy, increased anxiety.
Correct Answer: A
Rationale: characteristic behaviors associated with an acute manic episode include agitation, grandiose delusions, euphoria, and concentration problems; mania is a mood of extreme euphoria and is manifested by more extreme levels of behavior
A patient several days after an above-knee amputation (AKA).
Which of the following symptoms would be characteristic of an infected stump wound?
- A. The patient is anxious and restless.
- B. There is a small amount of dark drainage on the dressing.
- C. The patient complains of persistent pain at the operative site.
- D. The skin is cool above the operative site.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to an infected wound. (1) may be due to changes in body image or pain (2) expected, not indicative of an infection (3) correct-pain is characteristic of inflammation and infection (4) warm skin above site would indicate infection