Nokea
The nurse is observing a 3-year-old client for expected developmental milestones. It would require follow-up if the client cannot
- A. catch a ball at least 50% of the time
- B. copy a square with a pencil or crayon
- C. eat with a spoon
- D. hop on one foot
Correct Answer: B
Rationale: Copying a square is expected by age 4-5, not 3, indicating a fine motor delay requiring follow-up. Catching a ball, eating with a spoon, and hopping are age-appropriate or slightly advanced for a 3-year-old.
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The nurse is caring for a client with latent pulmonary tuberculosis who has been receiving isoniazid daily for the past 2 months. The client reports numbness and tingling in the hands and feet. The nurse should recognize that the client is likely experiencing a deficiency in
- A. iron
- B. vitamin B6
- C. folic acid
- D. vitamin D3
Correct Answer: B
Rationale: Isoniazid can deplete vitamin B6 (pyridoxine), causing peripheral neuropathy (numbness, tingling). Other deficiencies (iron, folic acid, vitamin D3) don't typically cause neuropathy.
The nurse is caring for a client who will not use the train for transportation due to the fear of being trapped and unable to escape. The nurse should recognize that the client is likely experiencing
- A. generalized anxiety disorder
- B. social anxiety disorder
- C. agoraphobia
- D. acrophobia
Correct Answer: C
Rationale: Fear of being trapped in situations (e.g., trains) with no escape is characteristic of agoraphobia. Generalized anxiety involves broad worries, social anxiety focuses on social scrutiny, and acrophobia is fear of heights.
A client is admitted for treatment of a right upper lobe infiltrate and to rule out tuberculosis. Which of these would be the most appropriate self-protective action by the nurse?
- A. Provide negative room ventilation
- B. Wear a face mask with shield
- C. Wear a particulate respirator mask
- D. Institute airborne precautions
Correct Answer: C
Rationale: Tight fitting, high-efficiency masks are required when caring for clients who have a suspected communicable disease of the airborne variety.
The nurse is caring for a client at 15 weeks gestation who has hyperemesis gravidarum. Which of the following findings would be consistent with the condition?
- A. heart rate less than 60/min
- B. moderate to high urine ketones
- C. increased serum potassium level
- D. blood pressure greater than 140/90 mm Hg
Correct Answer: B
Rationale: Hyperemesis gravidarum causes severe vomiting, leading to ketosis (moderate to high urine ketones) from fat breakdown. Bradycardia, hyperkalemia, and hypertension are not typical; tachycardia and hypokalemia may occur.
A client with a knee injury is scheduled for an MRI examination. The nurse explains the test to the client. Which finding in the client would make the client ineligible for this type of exam?
- A. Presence of a metal plate in the leg from an old fracture
- B. Presence of a ceramic artificial hip
- C. A history of asthma attacks
- D. Allergy to injected dye
Correct Answer: A
Rationale: A metal plate is a contraindication for MRI due to magnetic interference, making the client ineligible.