Nokea
The nurse is caring for clients in the pediatric clinic.
- A. Which finding in a six-month-old infant requires follow-up?
- B. The anterior fontanel is open.
- C. The child is not sitting unsupported.
- D. The child is not pulling to a standing position.
- E. The child is not rolling from abdomen to back.
Correct Answer: C
Rationale: By six months, infants typically pull to a standing position with support. Failure to do so may indicate developmental delay, requiring follow-up. An open anterior fontanel is normal until 18 months, sitting unsupported begins around 7-8 months, and rolling over is expected by 5-6 months.
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The nurse is caring for a client with a long history of alcohol and drug dependence. It would be MOST important for the nurse to include which of the following as a part of his discharge planning?
- A. Referral to a social service agency for assistance with housing.
- B. Referral to an aftercare center in the community.
- C. Participation in Alcoholics Anonymous (AA) meetings with a sponsor.
- D. A prescription for an antidepressant medication.
Correct Answer: C
Rationale: self-help groups have greatest success rate as a sustained support system in the community
The nurse is teaching a client about warfarin (Coumadin) therapy. Which of the following statements by the client indicates a need for further teaching?
- A. I will avoid contact sports while taking this medication.
- B. I will check with my doctor before taking any new medications.
- C. I will increase my intake of green leafy vegetables.
- D. I will report any unusual bleeding to my doctor.
Correct Answer: C
Rationale: green leafy vegetables are high in vitamin K, which can decrease the effectiveness of warfarin
A client received six units of regular insulin three hours ago.
- A. Which observation would be most concerning for a client who received six units of regular insulin three hours ago?
- B. Kussmaul respirations and diaphoresis.
- C. Anorexia and lethargy.
- D. Diaphoresis and trembling.
- E. Headache and polyuria.
Correct Answer: C
Rationale: Regular insulin peaks in 2-4 hours, and diaphoresis and trembling are classic signs of hypoglycemia, a potentially life-threatening complication requiring immediate intervention (e.g., administering skim milk). Kussmaul respirations indicate hyperglycemia, while anorexia, lethargy, headache, and polyuria are not specific to hypoglycemia.
The nurse is caring for a client with a history of seizures. The client begins to experience a tonic-clonic seizure. Which of the following actions should the nurse take FIRST?
- A. Restrain the client to prevent injury.
- B. Place a tongue depressor in the client's mouth.
- C. Turn the client to the side.
- D. Administer lorazepam (Ativan) IV.
Correct Answer: C
Rationale: turning the client to the side helps maintain a patent airway and prevents aspiration during a seizure
After receiving report, which of the following patients should the nurse see FIRST?
- A. A patient in sickle-cell crisis with an infiltrated IV.
- B. A patient with leukemia who has received one-half unit of packed cells.
- C. A patient scheduled for a bronchoscopy.
- D. A patient complaining of a leaky colostomy bag.
Correct Answer: A
Rationale: IV fluids are critical to reduce clotting and pain.