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The nurse is caring for a 24-month-old toddler who has sensory sensitivity, difficulty engaging in social interactions, and has not yet spoken two-word phrases. Which assessment should the nurse administer?
- A. Peabody Picture Vocabulary Test
- B. The Modified Checklist for Autism in Toddlers (M-CHAT)
- C. Wechsler Preschool and Primary Scale of Intelligence
- D. Denver Developmental Screening Test
Correct Answer: B
Rationale: The Modified Checklist for Autism in Toddlers (M-CHAT) is specifically designed to screen for autism spectrum disorders in young children. It is appropriate for this child, given the signs of social and communication delays. The Peabody Picture Vocabulary Test (Choice A) assesses receptive vocabulary and may not capture the social and communication aspects seen in autism. The Wechsler Preschool and Primary Scale of Intelligence (Choice C) measures cognitive ability and may not address the social and communication delays. The Denver Developmental Screening Test (Choice D) is a broad developmental assessment tool, but the M-CHAT is more specific to screening for autism in this case.
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A client in labor who received epidural anesthesia experiences a sudden drop in blood pressure. What action should the nurse take first?
- A. Administer oxygen via nasal cannula.
- B. Administer an intravenous fluid bolus.
- C. Prepare the client for an emergency cesarean section.
- D. Place the client in a lateral position.
Correct Answer: D
Rationale: In a client experiencing a sudden drop in blood pressure after epidural anesthesia, the first action the nurse should take is to place the client in a lateral position. This position helps improve venous return and cardiac output by relieving aortocaval compression. Administering oxygen via nasal cannula may be necessary if the client shows signs of respiratory distress, but it is not the first priority in this situation. Administering an intravenous fluid bolus can help stabilize blood pressure, but repositioning the client takes precedence. Preparing the client for an emergency cesarean section is not indicated solely based on a sudden drop in blood pressure after epidural anesthesia; this step would be considered if other complications arise.
A 17-year-old adolescent reports flu-like symptoms and is brought to the emergency room. What intervention should the nurse implement first?
- A. Assess the client's temperature.
- B. Place a mask on the client.
- C. Obtain a chest X-ray per protocol.
- D. Determine the client's blood pressure.
Correct Answer: B
Rationale: The correct answer is to place a mask on the client. This intervention is crucial in preventing the spread of infections like the flu, especially in a healthcare setting where the risk of transmission is high. Assessing the client's temperature (Choice A) can be important but is not the priority in this situation. Obtaining a chest X-ray (Choice C) and determining the client's blood pressure (Choice D) are not the immediate interventions needed for a 17-year-old reporting flu-like symptoms.
A client with type 2 diabetes mellitus arrives at the clinic reporting episodes of weakness and palpitations. Which finding should the nurse identify may indicate an emerging situation?
- A. History of hypertension
- B. Fingertips feel numb
- C. Reduced deep tendon reflexes
- D. Elevated fasting blood glucose level
Correct Answer: B
Rationale: Numb fingertips may suggest neuropathy, a common complication of diabetes that may indicate a worsening condition. Episodes of weakness and palpitations, combined with neuropathy symptoms, could also suggest hypoglycemia or poor glycemic control, requiring further investigation. The other choices are less likely to be directly related to the client's current symptoms. While a history of hypertension is a common comorbidity in clients with diabetes, it may not directly explain the reported weakness and palpitations. Reduced deep tendon reflexes are more indicative of certain neurological conditions rather than acute emerging situations related to the client's current symptoms. An elevated fasting blood glucose level is expected in a client with type 2 diabetes and may not be the primary indicator of an emerging situation in this context.
A client with Alzheimer's disease is exhibiting signs of agitation and aggression. What is the nurse's priority intervention?
- A. Reassure the client and provide emotional support.
- B. Redirect the client to a quiet activity.
- C. Administer a PRN dose of lorazepam.
- D. Apply soft restraints as needed to prevent harm.
Correct Answer: B
Rationale: The correct answer is to redirect the client to a quiet activity. This intervention helps reduce agitation and aggression in clients with Alzheimer's disease by providing a distraction and promoting a calming environment. Reassuring the client and providing emotional support (Choice A) can be beneficial but is not the priority in this situation. Administering a PRN dose of lorazepam (Choice C) should not be the first intervention due to the risk of adverse effects and should only be considered if other non-pharmacological interventions are ineffective. Applying restraints (Choice D) should be avoided unless absolutely necessary for the client's safety as it can lead to further distress and is not the initial priority intervention.
A client with hypertension is prescribed lisinopril. What side effect should the nurse teach the client to monitor for?
- A. Monitor for a persistent cough.
- B. Monitor for bradycardia and dizziness.
- C. Report any signs of swelling or difficulty breathing.
- D. Monitor for headache and blurred vision.
Correct Answer: A
Rationale: The correct answer is A: 'Monitor for a persistent cough.' Lisinopril, an ACE inhibitor, is associated with a common side effect of a persistent dry cough. This cough can be bothersome to the client and should be reported to their healthcare provider. Choices B, C, and D are incorrect because bradycardia, dizziness, swelling, difficulty breathing, headache, and blurred vision are not typically associated with lisinopril use.