Nokea
The nurse is caring for a 75-year-old client who is admitted to the hospital with pneumonia. What assessment finding is most consistent with the diagnosis of delirium?
- A. Client is experiencing muscle stiffness and resting hand tremors
- B. Client is inattentive and disoriented
- C. Client reports decreased enjoyment in hobbies
- D. Family reports a gradual inability to remember recent events
Correct Answer: B
Rationale: Inattention and disorientation are hallmark signs of delirium, especially in elderly clients with pneumonia. Other findings suggest different conditions.
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A client with a embolus has an order for a continuous infusion of heparin. The doctor has ordered 1,200 units per hour. If the solution contains 1,250 units in $250 \mathrm{~mL}$, the nurse should administer how many $\mathrm{mL}$ per hour?
- A. 12
- B. 24
- C. 36
- D. 48
Correct Answer: B
Rationale: Calculation: (1,200 units/hour ÷ 1,250 units) × 250 mL = 24 mL/hour. This ensures the correct heparin dose is delivered.
The nurse is reinforcing teaching for the parents of a child newly diagnosed with hemophilia. Which long-term complication is important for the nurse to discuss?
- A. Heart valve injury
- B. Intellectual disability
- C. Joint destruction
- D. Recurrent pneumonia
Correct Answer: C
Rationale: Hemophilia causes recurrent joint bleeds, leading to joint destruction (hemophilic arthropathy), a key long-term complication.
The nurse is making a home visit to the mother of an 8-lb baby boy born five days ago. Which observation indicates that the mother understands the care of the newborn?
- A. The mother is concerned about the fact that the baby has a soft stool after every breast feeding.
- B. The mother gives the baby a sponge bath but does not put him in a tub.
- C. The mother cleans the circumcised penis with alcohol when changing the diaper.
- D. The mother nurses the baby hourly.
Correct Answer: B
Rationale: Sponge baths are appropriate for newborns until the umbilical cord falls off, indicating proper care. Soft stools are normal, alcohol may irritate circumcision sites, and hourly nursing is excessive.
A 6 year-old female is diagnosed with recurrent urinary tract infections (UTIs). Which one of the following instructions would be best for the nurse to tell the caregiver?
- A. Increase bladder tone by delaying voiding
- B. When laundering clothing, rinse several times
- C. Use plain water for the bath, shampooing hair last
- D. Have the child use antibacterial soaps while bathing
Correct Answer: C
Rationale: Use plain water for the bath, shampooing hair last. Hair should be shampooed last with a rinsing of plain water over the genital area. The oils in soaps and bubble bath can cause irritation, which may lead to UTIs in young girls.
A newly admitted client describes symptoms of dizziness and feeling faint on standing. The client has a history of type 2 diabetes, coronary artery disease, and bipolar disorder. Which medications may be contributing to the client's symptoms? Select all that apply.
- A. Atorvastatin
- B. Metformin
- C. Metoprolol
- D. Olanzapine
- E. Omeprazole
Correct Answer: C,D
Rationale: Metoprolol, a beta-blocker, can cause orthostatic hypotension, leading to dizziness on standing. Olanzapine, an antipsychotic, is associated with orthostatic hypotension as a side effect. A, B, and E are not commonly linked to orthostatic symptoms; atorvastatin manages cholesterol, metformin controls blood sugar, and omeprazole reduces stomach acid.