Nokea
The nurse is discussing concerns the parent has with his 3-year-old. The parent identifies limitations in the child's activities. Select all that should be of concern to the nurse.
- A. unable to work simple toys
- B. unable to understand simple instructions
- C. unable to say first and last name
- D. unable to name any colors or numbers
Correct Answer: A,B,D
Rationale: By age 3, children should manipulate simple toys, follow simple instructions, and name some colors or numbers. These limitations (A, B, D) suggest developmental delays requiring further evaluation. Saying first and last name (C) is less critical at this age.
You may also like to solve these questions
Which of the following statements best describes compartment syndrome?
- A. An injury causes pain and tingling that starts in the buttock and travels down the leg.
- B. An injury causes swelling within muscle tissue that leads to anoxia of nerves and muscles.
- C. An injury causes permanent flexion of the interphalangeal joint, resulting in deformity.
- D. An injury causes pain and swelling of the median plantar nerve.
Correct Answer: B
Rationale: Compartment syndrome is characterized by swelling and increased pressure within a muscle compartment, leading to decreased blood flow and oxygen supply to nerves and muscles. This can result from various causes, such as trauma or the application of a cast after a fracture. If left untreated, compartment syndrome can lead to tissue necrosis. Choice A is incorrect as pain and tingling starting in the buttock and traveling down the leg are not specific features of compartment syndrome. Choice C is incorrect as permanent flexion of the interphalangeal joint is unrelated to compartment syndrome. Choice D is incorrect as pain and swelling of the median plantar nerve do not describe compartment syndrome.
A nurse is caring for a 3-day old infant who needs an exchange transfusion. Which of the following statements is appropriate for teaching the child's parents about this procedure?
- A. The registered nurse will be performing the procedure
- B. The procedure takes approximately 1 ? hours.
- C. The nurse will draw out 250cc of blood and then immediately replace it with 250cc
- D. The infant will continue to receive phototherapy during the procedure.
Correct Answer: B
Rationale: : An exchange transfusion is a method of controlling high bilirubin levels in infants when traditional phototherapy is unsuccessful. During an exchange transfusion, the physician removes 5-10 cc of blood and then replaces it with donor blood. The parents of this infant should know that the procedure is always performed by a physician and will take approximately 1 ½ hours to complete.
The nurse has provided instructions to a client being discharged from the hospital to home after an abdominal aortic aneurysm (AAA) resection. The nurse determines that the client understands the instructions if the client states that which is an appropriate activity?
- A. Mowing the lawn
- B. Playing a game of 18-hole golf
- C. Lifting objects up to 30 pounds
- D. Walking as tolerated, including outdoors
Correct Answer: D
Rationale: Walking as tolerated is appropriate post-AAA resection, promoting circulation without straining the graft. Mowing, golf, and lifting over 15–20 pounds are prohibited for 6–12 weeks to avoid graft stress.
Which client does the nurse recognize as having the highest increased risk of developing breast cancer?
- A. a 68-year-old client with dense breasts
- B. a 34-year-old client pregnant with her first child
- C. an obese client with a body mass index of 30
- D. a client with two first-degree relatives with breast cancer
Correct Answer: D
Rationale: Family history with two first-degree relatives significantly increases breast cancer risk more than age, pregnancy, or obesity.
The nurse is teaching a client about dietary modifications to control hypertension. Which statement by the client indicates a need for further teaching?
- A. I can have a cup of fresh fruit as a snack.
- B. Baked ham is a good dinner choice for me.
- C. I need to check the label for sodium in ketchup.
- D. I need to cut out frozen pizza as a fast meal option.
Correct Answer: B
Rationale: Baked ham is high in sodium, which is unsuitable for hypertension. Other choices align with low-sodium dietary recommendations.