Nokea
The nurse is caring for a client receiving chemotherapy.
- A. Which symptom should the nurse report immediately for a client receiving chemotherapy?
- B. Nausea and vomiting.
- C. A temperature of 100.8°F (38.2°C).
- D. Fatigue and weakness.
- E. Alopecia.
Correct Answer: B
Rationale: A temperature of 100.8°F indicates possible infection, a life-threatening complication in chemotherapy patients due to immunosuppression. Nausea, fatigue, and alopecia are expected side effects but less urgent.
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A child in the waiting room who can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet.
The nurse identifies the child's chronological age to be
- A. 1 year old.
- B. 2 years old.
- C. 3 years old.
- D. 5 years old.
Correct Answer: C
Rationale: Strategy: Picture the child at each age. (1) unable to walk up and down stairs with hand held until 18 months (2) unable to jump until 30 months (3) correct-able to jump with both feet and stand on one foot momentarily at 30 months (4) behaviors are seen in younger child
The nurse is screening an eight-month-old girl in a well-baby clinic. The nurse would be MOST concerned if the infant's mother made which of the following statements?
- A. My daughter has almost doubled her birth weight.
- B. When I walk in the room my child smiles at me.
- C. When she is around her grandpa, my child cries.
- D. My daughter can't quite say Mama yet.
Correct Answer: A
Rationale: An eight-month-old should have doubled birth weight by 5–6 months; 'almost doubled' suggests growth delay, requiring evaluation. Options B, C, and D are normal behaviors.
After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room.
- A. Which assessment finding three hours after admission should be reported to the physician for a five-year-old with a closed head injury?
- B. The client has slight edema of the eyelids.
- C. There is clear fluid draining from the client’s right ear.
- D. There is some bleeding from the child’s lacerations.
- E. The client withdraws in response to painful stimuli.
Correct Answer: B
Rationale: Clear fluid draining from the ear suggests cerebrospinal fluid (CSF) leakage due to a meningeal rupture, a serious complication that risks meningitis and requires immediate reporting. Eyelid edema, minor bleeding, and withdrawal to pain are less urgent or expected findings.
To minimize the side effects of a DPT immunization for a six-month-old.
The nurse should instruct the parents to
- A. give the child an alcohol bath for an elevated temperature.
- B. administer antipyretics for discomfort, irritability, and fever.
- C. place an ice bag on the child's leg for one hour.
- D. check the child's temperature every four hours for three days.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. Is it desired? (1) implementation, uncomfortable and unnecessary (2) correct-implementation, antipyretics relieve the combination of side effects (3) implementation, dangerous to both skin integrity and overall temperature control (4) assessment, unnecessary unless indicated for another reason
An adult has experienced significant vomiting and diarrhea for the past 24 hours. Her chloride level is 90 mEq/L. What would the nurse expect to find when interpreting her sodium level?
- A. It would be high.
- B. It is impossible to predict the sodium level with this information.
- C. It would be low.
- D. It would be normal.
Correct Answer: C
Rationale: Vomiting and diarrhea cause sodium loss, likely resulting in a low sodium level, consistent with a low chloride level.