Nokea
The nurse is collecting data from an 18-month-old client. The nurse should suggest referral for a developmental screening test if the client
- A. does not notice when others are upset
- B. eats food using the fingers
- C. follows 1-step commands without gestures
- D. has a vocabulary of 5 words
Correct Answer: D
Rationale: An 18-month-old should have a vocabulary of 10-20 words. A vocabulary of only 5 words indicates a potential speech delay, warranting developmental screening. Noticing others' emotions develops later, finger-eating is normal, and following 1-step commands is age-appropriate.
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A hospitalized client has just been informed that he has terminal cancer. He says to the nurse, 'There must be some mistake in the diagnosis.' The nurse determines that the client is demonstrating which of the following?
- A. denial
- B. anger
- C. bargaining
- D. acceptance
Correct Answer: A
Rationale: Denial, per Kübler-Ross's
The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose. Which action would be appropriate?
- A. Lavage through a small-bore nasogastric tube
- B. Place client in Trendelenburg position during lavage
- C. Prepare intubation and suction supplies at the bedside
- D. Wait an hour after gastric decompression to initiate lavage
Correct Answer: C
Rationale: Preparing intubation and suction supplies ensures readiness for airway protection, as gastric lavage carries a risk of aspiration. Small-bore tubes are inadequate for lavage, Trendelenburg increases aspiration risk, and waiting an hour delays urgent treatment.
Narrow therapeutic index medications:
- A. are drug formulations with limited pharmacokinetic variability.
- B. have limited value and require no monitoring of blood levels.
- C. have less than a twofold difference in minimum toxic levels and minimum effective concentration in the blood.
- D. have limited potency and side effects.
Correct Answer: C
Rationale: Narrow therapeutic index drugs have a small margin between effective and toxic doses, requiring close monitoring. The other descriptions are inaccurate or irrelevant. Pharmacological Therapies
The nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate?
- A. Allow the infant to drink the liquid from a medicine cup
- B. Administer the medication with a syringe next to the tongue
- C. Mix the medication with the infant's formula in the bottle
- D. Hold the child upright and administer the medicine by spoon
Correct Answer: B
Rationale: Using a needle-less syringe to give liquid medicine to an infant is often the safest method. If the nurse directs the medicine toward the side or the back of the mouth, gagging will be reduced.
An adult has a substance abuse problem. Which statement, if made by the client, indicates the best understanding of the problem?
- A. I can never use that drug again.'
- B. When I am off the drug for two years, I will be cured.'
- C. At least I shall be able to go to parties and limit my drugs.'
- D. When I feel upset, I can call the support group.'
Correct Answer: D
Rationale: Calling a support group during distress shows understanding of ongoing recovery needs, leveraging resources to maintain sobriety.