Nokea
The nurse is discussing activities to promote language development with the parent of a 2-year-old. Which statement by the parent requires follow-up?
- A. I have dress-up clothes set out for my child to play with.
- B. I read brightly-colored picture books with rhymes with my child
- C. I set out a basket of toy cars when other children come to play
- D. I will enroll my child to play on a soccer team
Correct Answer: D
Rationale: Enrolling a 2-year-old in soccer is premature, as it does not directly promote language development and is not age-appropriate. Reading rhyming books and facilitating peer play with toys support language skills.
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A veteran is admitted with a diagnosis of chronic post-traumatic stress disorder. After being placed in the treatment room, he begins to pace frantically and make references to 'highway one.' As the nurse approaches him, he retreats to the corner and sits on the floor with his arms and legs pulled tight to his body. The client is experiencing a:
- A. Hallucination
- B. Phobic reaction
- C. Delusion
- D. Flashback
Correct Answer: D
Rationale: The behavior and reference to 'highway one' suggest a flashback, where the client is reliving a traumatic event, common in PTSD.
The nurse is caring for a client with type 2 diabetes mellitus who is receiving a thiazolidinedione. Which of the following findings would require immediate follow-up?
- A. 2+ pitting edema in the lower legs bilaterally
- B. blood pressure of 140/88 mm Hg
- C. elevated triglyceride level
- D. elevated hemoglobin A1c
Correct Answer: A
Rationale: Thiazolidinediones (eg, rosiglitazone, pioglitazone) are oral antidiabetic medications used to manage hyperglycemia in clients with type 2 diabetes mellitus. Thiazolidinediones increase the sensitivity of insulin receptors, which improves insulin efficacy and prevents large rises in blood glucose after meals. It is a priority for the nurse to report signs of heart failure (eg, bilateral pitting edema, rapid weight gain, crackles) to the health care provider because thiazolidinediones can cause heart failure due to fluid retention. The client may require a lower thiazolidinedione dose or therapy with a different oral antidiabetic agent (eg, metformin).
A 3 year-old child is treated in the emergency department after ingestion of 1 ounce of a liquid narcotic. What action should the nurse perform first?
- A. Provide the ordered humidified oxygen via mask
- B. Suction the mouth and the nose
- C. Check the mouth and radial pulse
- D. Start the ordered intravenous fluids
Correct Answer: C
Rationale: Check the mouth and radial pulse. Assessing airway, breathing, and circulation is the first step in treating toxic ingestion to stabilize the client.
The nurse is caring for a client diagnosed with polycythemia vera. Which statement by the client requires immediate follow-up?
- A. I am trying to find makeup to cover my unattractive, ruddy facial complexion
- B. I massage my sore leg to help bring the swelling down
- C. I take low-dose aspirin to relieve my occasional headaches
- D. My skin itches so severely, and no lotion or cream seems to help
Correct Answer: B
Rationale: Massaging a sore, swollen leg risks dislodging a clot in polycythemia vera, which predisposes to thrombosis. Ruddy complexion, aspirin use, and itching are expected but less urgent.
The nurse is preparing the sterile field and supplies for a wet-to-damp dressing change. Which of the following actions by the nurse would require follow-up?
- A. Drop sterile gauze on the sterile field from 6 inches (15cm ) above
- B. Keeps the sterile field and sterile gloved hands within view at all times
- C. Places sterile gauze 2 inches (5 cm) inside the outer edge of the sterile drape
- D. Pours sterile saline solution from a recapped bottle opened 30 hours ago
Correct Answer: D
Rationale: Using saline from a bottle opened 30 hours ago risks contamination, as sterile solutions are typically discarded after 24 hours. Keeping the field in view and placing gauze appropriately maintain sterility.