Nokea
The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is
- A. touching the trapezius muscle or arm firmly
- B. pinching any body part
- C. shaking a limb vigorously
- D. rubbing the sternum
Correct Answer: D
Rationale: rubbing the sternum. The purpose is to assess the non-responsive client's reaction to a painful stimulus after less noxious methods have been tried.
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A nurse is teaching a patient about the use of albuterol (Proventil) for asthma. Which of the following instructions should be included?
- A. Use this medication daily to prevent asthma attacks.
- B. Use this medication only when you feel short of breath.
- C. Use this medication at bedtime.
- D. Use this medication before exercise.
Correct Answer: D
Rationale: Albuterol, a rescue inhaler, is used before exercise to prevent exercise-induced bronchospasm. It’s not for daily prevention, symptom-only use, or bedtime dosing.
What finding signifies that children have attained the stage of concrete operations (Piaget)?
- A. Explores the environment with the use of sight and movement
- B. Thinks in mental images or word pictures
- C. Makes the moral judgment that 'stealing is wrong'
- D. Reasons that homework is time-consuming yet necessary
Correct Answer: C
Rationale: The stage of concrete operations is depicted by logical thinking and moral judgments.
Which of the following lab reports indicates that a client with acute glomerulonephritis is improving?
- A. Positive ASO titer
- B. Increased C reactive protein
- C. Negative eosinophil count
- D. Decreased erythrocyte sedimentation rate
Correct Answer: D
Rationale: A decreased erythrocyte sedimentation rate indicates reduced inflammation, suggesting improvement in acute glomerulonephritis.
A nurse is caring for a pregnant patient in her third trimester. Which of the following findings should be reported immediately?
- A. Mild edema in the lower extremities
- B. Heartburn
- C. Severe headache and visual disturbances
- D. Frequent urination
Correct Answer: C
Rationale: Severe headache and visual disturbances suggest preeclampsia, a medical emergency. Mild edema, heartburn, and frequent urination are normal in late pregnancy.
As a general guide for emergency management of acute alcohol intoxication, it is important for the nurse initially to obtain data regarding which of the following?
- A. What and how much the client drinks, according to family and friends
- B. The blood alcohol level of the client
- C. The blood pressure level of the client
- D. The blood glucose level of the client
Correct Answer: B
Rationale: Blood alcohol levels are generally obtained to determine the level of intoxication. The amount of alcohol consumed determines how much medication the client needs for detoxification and treatment. Reports of alcohol consumption are notoriously inaccurate.