Nokea
The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?
- A. Stand on 1 foot
- B. Catch a ball
- C. Skip on alternate feet
- D. Ride a bicycle
Correct Answer: A
Rationale: Stand on 1 foot. Balancing on one foot is expected by age 3, indicating gross motor delay if absent.
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A client with symptoms supportive of a diagnosis of Guillain-Barré syndrome.
The nurse knows that which of the following symptoms would be supportive of a diagnosis of Guillain-Barré syndrome?
- A. Hemiplegia, hypertension, tachycardia.
- B. Respiratory failure, flaccid paralysis, urinary retention.
- C. Peripheral edema, hypertension, pulmonary congestion.
- D. Diminished reflexes, pain, paresthesia.
Correct Answer: B
Rationale: Strategy: All parts of the answer choice must be correct in order for the answer to be correct. (1) relates to a CVA (2) correct-classic symptoms include respiratory failure and flaccidity due to paralysis of the muscles and urinary retention due to loss of sensation (3) relates to pulmonary edema (4) relates to peripheral nerve problems
Which client should receive a private room?
- A. A client with diabetes
- B. A client with Cushing's disease
- C. A client with Graves' disease
- D. A client with gastric ulcers
Correct Answer: D
Rationale: A client with gastric ulcers may have Helicobacter pylori infection, which can be contagious and requires isolation precautions. Clients with diabetes, Cushing's disease, or Graves' disease do not typically require private rooms unless they have a contagious condition.
The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
- A. Decreased urinary output
- B. Hypersomnolence
- C. Absence of knee jerk reflex
- D. Decreased respiratory rate
Correct Answer: B
Rationale: Hypersomnolence is an expected side effect of magnesium sulfate due to its sedative properties, so B is correct. Decreased urinary output , absence of knee jerk reflex , and decreased respiratory rate are signs of toxicity, not expected effects.
The nurse is preparing to discharge a client after an abdominal cholecystectomy for treatment of cholelithiasis. The client will go home with a T-tube in place. Which of the following statements, if made by the client to the nurse, indicates a need for further teaching?
- A. It will be great to finally get home, take a shower, and wash my hair.
- B. If the amount of drainage increases over the next several days, I should call my physician.
- C. I can resume swimming laps three times a week at my health club.
- D. I will check the skin around the tube once a day to see how it is doing.
Correct Answer: C
Rationale: Swimming submerges the T-tube, risking infection, indicating a need for further teaching. Options A, B, and D are correct: showering is allowed, increased drainage requires reporting, and daily skin checks prevent complications.
A client admitted with a severe head injury following an MVA is placed on a ventilator, and hyperventilation is maintained. The primary reason for maintaining hyperventilation is:
- A. To increase oxygen to the brain
- B. To dilate the cerebral blood volume
- C. To increase the cerebral blood volume
- D. To promote cerebral vasoconstriction and decrease cerebral blood flow
Correct Answer: D
Rationale: Hyperventilation reduces $\mathrm{CO}_2$, causing cerebral vasoconstriction, which decreases cerebral blood flow and intracranial pressure in head injuries.