Nokea
The nurse is collecting data from a client during a routine physical examination. Which of the following findings would be most important to report to the health care provider?
- A. BMI of 30 kg/m²
- B. Brownish skin thickening on the neck
- C. Cholesterol level
- D. Round 3x3 mm pale pink mole
Correct Answer: B
Rationale: Brownish skin thickening on the neck may indicate acanthosis nigricans, associated with insulin resistance or diabetes, requiring prompt reporting.
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The nurse is teaching the parent of a 6-year-old client about sleep. Which of the following information should the nurse include? Select all that apply.
- A. Your child should sleep 9 to 12 hours every night.
- B. As your child grows, the hours of required sleep increase.
- C. Encourage active play before bedtime to promote restful sleep.
- D. Avoid giving your child large amounts of liquid after dinnertime.
- E. It is important to establish and maintain a regular bedtime routine.
Correct Answer: A,D,E
Rationale: Children aged 6 need 9-11 hours of sleep, limited liquids prevent bedwetting, and routines promote sleep. Sleep needs decrease with age, and active play close to bedtime may disrupt sleep.
The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules. The client states 'I cannot take the medication in this form.' What is the nurse's first action?
- A. Ask the health care provider to prescribe a different calcium channel blocker
- B. Consult with the pharmacist to see if an alternate form of the drug is available
- C. Open the capsule and sprinkle the medication in a cup of applesauce
- D. Warn the client about the dangers of uncontrolled hypertension
Correct Answer: B
Rationale: The client may object to gelatin in capsules due to dietary restrictions. Consulting the pharmacist for an alternative form respects the client's beliefs.
The nurse is reinforcing discharge instructions to the parent of a child with Kawasaki disease. The nurse informs the parent that the presence of which symptom should be immediately reported to the health care provider?
- A. Fever
- B. Irritability
- C. Joint pain
- D. Skin peeling
Correct Answer: A
Rationale: Fever in Kawasaki disease may indicate persistent inflammation or complications, requiring immediate reporting.
An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused by
- A. Tachypnea
- B. Acidic byproducts
- C. Aspirin poisoning and dehydration
- D. Hyperpyrexia
Correct Answer: A
Rationale: Tachypnea. Stimulation of respiratory center leads to hyperventilation, thus decreasing CO2 levels which causes respiratory alkalosis.
The nurse reinforces teaching for the parents of a child with impetigo. Which of the following statements by a parent indicates correct understanding of teaching? Select all that apply.
- A. I should wash my hands before and after touching the infected area.
- B. I will clean the infected area with alcohol before applying the antibiotic ointment.
- C. I will separate my child's clothing from other laundry and wash them with hot water.
- D. My child's fingernails should be kept short and well-filed.
- E. The infection could easily spread to other children who come in contact with my child.
Correct Answer: A,C,D,E
Rationale: Hand hygiene, separating laundry, keeping nails short, and recognizing the contagious nature of impetigo are correct. Cleaning with alcohol is inappropriate as it may irritate the skin.