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The nurse is performing a mental health assessment on a 5-year-old girl. Her parents are in the middle of a bitter divorce and are worried about the effect it is having on their daughter. Which of the following might lead the nurse to be concerned about the girl's mental health?
- A. She clings to her mother whenever the nurse is in the room.
- B. She appears angry and will not make eye contact with the nurse.
- C. Her mother states that the girl has begun to ride a tricycle around their yard.
- D. Her mother states that her daughter prefers to play with toddlers instead of kids her own age while in daycare.
Correct Answer: D
Rationale: The correct answer is D because it indicates a potential concern about the girl's mental health. This behavior may suggest a difficulty in socializing with peers of her own age, which could be a sign of emotional distress or developmental issues. This is concerning in the context of her parents' bitter divorce.
A: Clinging to her mother is a common behavior for a child going through a stressful situation, so it may not necessarily indicate a mental health issue.
B: Appearing angry and avoiding eye contact could also be a normal reaction to stress or discomfort.
C: Riding a tricycle is a typical activity for a 5-year-old and may not directly relate to mental health concerns.
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A patient with chronic kidney disease (CKD) is being assessed. The nurse would expect to find which of the following symptoms?
- A. Weight loss and polyphagia.
- B. Edema and proteinuria.
- C. Hypertension and tachycardia.
- D. Hypothermia and bradycardia.
Correct Answer: B
Rationale: The correct answer is B: Edema and proteinuria. In CKD, the kidneys are unable to filter waste products effectively, leading to fluid retention (edema) and protein leaking into the urine (proteinuria). Edema occurs due to fluid buildup from decreased kidney function. Proteinuria is a result of damaged glomeruli in the kidneys, allowing proteins to leak into the urine. Weight loss and polyphagia (excessive hunger) are not typical symptoms of CKD. Hypertension and tachycardia can occur in CKD due to fluid overload and electrolyte imbalances. Hypothermia and bradycardia are not common symptoms of CKD and would be more indicative of other conditions.
A nurse is caring for a patient with chronic kidney disease (CKD). Which of the following lab results would the nurse expect to be elevated in this patient?
- A. Blood urea nitrogen (BUN).
- B. Calcium.
- C. Potassium.
- D. Sodium.
Correct Answer: A
Rationale: The correct answer is A: Blood urea nitrogen (BUN). In CKD, the kidneys are unable to effectively filter waste products, leading to an increase in BUN levels. Elevated BUN indicates impaired kidney function. Calcium, potassium, and sodium levels may also be affected in CKD, but they are more likely to be imbalanced rather than consistently elevated. Calcium levels may be low due to impaired vitamin D activation, potassium levels may be high due to decreased excretion, and sodium levels can fluctuate based on fluid status. Therefore, while these lab values may be abnormal in CKD, BUN is the most consistently elevated marker of kidney dysfunction.
Which intervention should the nurse implement for a client who is experiencing a seizure?
- A. Place the client on their side and protect their head
- B. Loosen the client's clothing and ensure safety
- C. Monitor the client's airway and give oxygen
- D. Administer antiepileptic medications
Correct Answer: D
Rationale: The correct answer is D, administering antiepileptic medications. This is because during an active seizure, the priority is to stop the seizure activity. Antiepileptic medications are specifically designed to prevent or reduce the frequency and intensity of seizures. Placing the client on their side and protecting their head (choice A) is important for safety but does not address stopping the seizure. Loosening clothing and ensuring safety (choice B) is also important but does not directly address the seizure itself. Monitoring airway and giving oxygen (choice C) is crucial but does not actively stop the seizure. Therefore, administering antiepileptic medications is the most appropriate intervention to address the root cause of the seizure.
What is the best way to assess a client's nutritional status?
- A. Obtain a dietary history
- B. Monitor serum albumin levels
- C. Monitor the client's weight
- D. Provide a meal plan
Correct Answer: B
Rationale: The correct answer is B: Monitoring serum albumin levels. This is because serum albumin is a protein synthesized by the liver that reflects long-term protein intake and overall nutritional status. Low levels indicate malnutrition or inflammation. Obtaining a dietary history (choice A) is important but may not always reflect the actual nutritional status. Monitoring weight (choice C) is helpful but may not provide a comprehensive view of the client's nutritional status. Providing a meal plan (choice D) is a proactive approach but does not directly assess the client's current nutritional status.
Which quadrant of the abdomen is tender in suspected appendicitis?
- A. upper right
- B. upper left
- C. lower right
- D. lower left
Correct Answer: C
Rationale: The correct quadrant for tenderness in suspected appendicitis is the lower right quadrant (Choice C). This is because the appendix is located in the lower right abdomen. Appendicitis typically presents with pain starting around the navel and then localizing to the lower right quadrant. The other choices, upper right (Choice A), upper left (Choice B), and lower left (Choice D) are incorrect as they do not correspond to the typical location of the appendix. Upper right quadrant is where the liver and gallbladder are situated, upper left quadrant contains the stomach and spleen, and lower left quadrant has the colon and left ovary/testis.