Nokea
The nurse caring for a 2-year-old client should expect the child to be able to perform which of the following actions? Select all that apply.
- A. Draw a square
- B. Hop on one foot
- C. Kick a large ball
- D. Use 2-word phrases
- E. Walk without help
Correct Answer: C, D, E
Rationale: A 2-year-old can kick a ball (C), use 2-word phrases (D), and walk without help (E). Drawing a square (A) and hopping on one foot (B) are skills typically developed later.
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Diagnosis-related groups (DRGs) provide data to
- A. Identify clients who have specific medical diagnoses
- B. Identify findings related to a medical diagnosis
- C. Determine reimbursement for a medical diagnosis
- D. Implement nursing care based on case management protocol
Correct Answer: C
Rationale: Determine reimbursement for a medical diagnosis. DRGs are the basis of prospective payment plans for reimbursement for Medicare clients.
The nurse is reinforcing teaching about hypoglycemia with a group of clients who have type 1 diabetes mellitus. Which of the following should the nurse include as signs or symptoms of hypoglycemia? Select all that apply.
- A. Diaphoresis
- B. Flushing
- C. Pallor
- D. Polyuria
- E. Trembling
Correct Answer: A, C, E
Rationale: Diaphoresis (A), pallor (C), and trembling (E) are signs of hypoglycemia due to sympathetic activation. Flushing (B) and polyuria (D) are not typical.
Parents of a 6 month-old breast fed baby ask the nurse about increasing the baby's diet. Which of the following should be added first?
- A. Cereal
- B. Eggs
- C. Meat
- D. Juice
Correct Answer: A
Rationale: Cereal. Strained cereal is recommended as the first solid food for breastfed infants, per pediatric guidelines.
The clinic nurse is reinforcing teaching to a client about the advance directive form that needs to be completed. Which statement indicates that the client understands the information?
- A. I will give a copy of this to my daughter, who is listed as my health care proxy.'
- B. I will need to get this approved by my doctor before it goes into effect.'
- C. I will put this on my refrigerator so no one will give me cardiopulmonary resuscitation.'
- D. You and my daughter can witness this for me.'
Correct Answer: A
Rationale: Giving a copy to the health care proxy (A) ensures the advance directive is communicated. Doctor approval (B), refrigerator posting (C), and nurse witnessing (D) are incorrect or unnecessary.
A female client seen in the health department's STD clinic is diagnosed with chlamydia. Before the client leaves the clinic, the nurse should:
- A. Obtain the names and addresses of the client's sexual contacts.
- B. Tell the client to avoid alcohol while taking her prescription for Flagyl.
- C. Instruct the client to avoid sexual relations until the infection is resolved.
- D. Tell the client to douche after sexual intercourse.
Correct Answer: C
Rationale: Avoiding sexual relations prevents chlamydia spread until treatment is complete. Contact tracing is secondary, Flagyl is for trichomoniasis, and douching is harmful.