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The nurse correctly explains that, during adolescence, being with a peer group and mimicking peer behaviors is part of the process of achieving which developmental task?
- A. Identity
- B. Intimacy
- C. Integrity
- D. Idealism
Correct Answer: A
Rationale: Adolescence involves developing a sense of identity, often through peer group interactions and mimicking behaviors, as teens explore their place in the world.
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The most common side effect of tocolytic agents is:
- A. Vaginal bleeding.
- B. Abdominal pain.
- C. Nausea,vomiting.
- D. Palpitations.
- E. Oliguria.
Correct Answer: D
Rationale: Tocolytics such as beta-agonists commonly cause palpitations due to their sympathomimetic effects. Other side effects are less frequent or not primarily associated.
Which finding documented by the nurse is most indicative of the presence of a Curling's ulcer in the burned child?
- A. Absence of bowel sounds
- B. A positive hemoccult test
- C. An elevated hematocrit
- D. A distended abdomen
Correct Answer: B
Rationale: A positive hemoccult test indicates gastrointestinal bleeding, characteristic of a Curling's ulcer, a stress ulcer common in burn patients due to physiological stress and reduced mucosal protection.
The nurse is caring for the infant in the neonatal ICU who has an umbilical artery catheter (UAC) in place. To monitor for and prevent complications with this catheter,which actions should be planned by the nurse? Select all that apply.
- A. Check the position marking on the catheter every shift.
- B. Position the tubing close to the infant’s lower limbs.
- C. Check for erythema or discoloration of the abdominal wall.
- D. Palpate for femoral,pedal,and tibial pulses every 2 to 4 hours.
- E. Reposition the catheter tubing every hour.
- F. Monitor blood glucose levels.
Correct Answer: A,C,D,F
Rationale: Check catheter position abdominal wall pulses every 2–4 hours and glucose levels to monitor for displacement bleeding perfusion issues or hypoglycemia. Keep tubing away from limbs and avoid frequent repositioning to reduce infection risk.
Which nursing actions are most appropriate to include in the care plan of a child with nephrotic syndrome? Select all that apply.
- A. Restricting the intake of protein
- B. Weighing the child daily
- C. Completing range-of-motion exercises
- D. Measuring abdominal circumference
- E. Collecting a 24-hour urine specimen
- F. Monitoring blood urea nitrogen (BUN) and creatinine levels
Correct Answer: B,C,D,E,F
Rationale: Daily weighing monitors fluid status, range-of-motion exercises prevent immobility complications, measuring abdominal circumference tracks ascites, collecting urine assesses proteinuria, and monitoring BUN/creatinine evaluates kidney function. Protein restriction is not typical.
Which response by the nurse best explains why aspirin is preferred to acetaminophen (Tylenol) in the treatment of rheumatic fever?
- A. Aspirin controls fever better.
- B. Aspirin prevents infections.
- C. Aspirin relieves joint inflammation.
- D. Aspirin prevents cardiac enlargement.
Correct Answer: C
Rationale: Aspirin is preferred in rheumatic fever due to its anti-inflammatory properties, which relieve joint inflammation and pain associated with polyarthritis. Acetaminophen lacks significant anti-inflammatory effects, making aspirin more effective.