Nokea
The nurse is caring for a 10-year-old client with osteomyelitis. Which of the following actions should the nurse take to promote age-appropriate growth and development during hospitalization?
- A. Ask the parent to bring schoolwork for the client to complete
- B. Encourage the client to engage in imaginary play with animal puppets
- C. Explain procedures to the client immediately before they are performed
- D. Provide opportunities for the client to play independently
Correct Answer: A
Rationale: Schoolwork supports cognitive development for a 10-year-old. Imaginary play suits younger children, last-minute explanations increase anxiety, and independent play may not meet social needs.
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The nurse employed in a woman's health care clinic would be most concerned about which client statement?
- A. I recently noticed a small, round, painless, mobile lump in my left breast while showering.
- B. Last night while breastfeeding, my nipples were cracked and my breasts were painful.
- C. My right breast is red and warm with little tiny indented areas on the surface of the skin.
- D. Sometimes during my cycle, I notice breast nodules that are movable and feel soft to the touch.
Correct Answer: C
Rationale: Red, warm breast with indented skin suggests inflammatory breast cancer, requiring urgent evaluation. A mobile lump is often benign, nipple pain is common in breastfeeding, and cyclic nodules are typically hormonal.
Discharge medications
Aspirin: 81 mg by mouth, once daily
Clopidogrel: 75 mg by mouth, once daily
Rivaroxaban: 20 mg by mouth, once daily
Metoprolol: 25 mg by mouth, twice daily
Rosuvastatin: 20 mg by mouth, once daily
Lisinopril: 10 mg by mouth, once daily
A client with coronary artery disease and atrial fibrillation is being discharged home following coronary artery stent placement. Discharge medications are shown in the exhibit. The nurse identifies which educational topic as the highest priority to reinforce for this client?
- A. Bleeding risk
- B. Bronchospasm
- C. Muscle injury
- D. Tinnitus
Correct Answer: A
Rationale: Anticoagulants/antiplatelets for CAD/AF increase bleeding risk , the highest priority. Bronchospasm , muscle injury , and tinnitus are less relevant.
The nurse is caring for a client receiving Theodur (theophylline). Side effects associated with bronchodilators include:
- A. Irritability, rapid pulse, and palpitations
- B. Slow pulse, increased appetite, and sweating
- C. Anxiety, nausea, and increased blood pressure
- D. Drowsiness, vomiting, and decreased blood sugar
Correct Answer: A
Rationale: Theophylline can cause irritability, rapid pulse, and palpitations due to its stimulant effects. Slow pulse , drowsiness , or decreased blood sugar are not typical.
After obtaining a nutritional assessment of an elderly client, the nurse determines that the client's diet lacks sufficient protein. Which foods represent low-cost sources of protein?
- A. Potatoes and beef
- B. Peas and beans
- C. Tomatoes and beets
- D. Pork and rice
Correct Answer: B
Rationale: Peas and beans are low-cost, high-protein foods. Beef and pork are expensive, and potatoes, tomatoes, beets, and rice are low in protein.
Which of the following nursing assessment findings require immediate discontinuance of an antipsychotic medication?
- A. Involuntary rhythmic stereotypic movements and tongue protrusion
- B. Cheek puffing, involuntary movements of extremities and trunk
- C. Agitation, constant state of motion
- D. Hyperpyrexia, severe muscle rigidity, malignant hypertension
Correct Answer: D
Rationale: Hyperpyrexia, severe muscle rigidity, and malignant hypertension are signs of neuroleptic malignant syndrome (NMS), requiring immediate discontinuation of the antipsychotic.