Nokea
The nurse is planning care for a 2 year-old hospitalized child. Which of the following will produces the most stress at this age?
- A. Separation anxiety
- B. Fear of pain
- C. Loss of control
- D. Bodily injury
Correct Answer: A
Rationale: Separation anxiety. While a toddler will experience all of the stresses, separation from parents is the major stressor.
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A client is placed on cephalexin monohydrate (Keflex) prophylactically after surgery.
Which of the following foods should the nurse encourage?
- A. Bran cereals and fruits.
- B. Egg whites and lean meats.
- C. Yogurt and acidophilus milk.
- D. Fish and poultry meats.
Correct Answer: C
Rationale: Strategy: The topic of the question unstated. Read the answer choices for clues. (1) unnecessary to encourage (2) unnecessary to encourage (3) correct-these foods will help maintain normal inTest inal flora, which may be altered by the Keflex (4) unnecessary to encourage
What must be the priority consideration for nurses when communicating with children?
- A. Present environment
- B. Physical condition
- C. Nonverbal cues
- D. Developmental level
Correct Answer: D
Rationale: While each of the factors affects communication, the nurse recognizes that developmental differences have implications for processing and understanding information. Consequently, a child's developmental level must be considered when selecting communication approaches.
The nurse is caring for a client with a history of rheumatoid arthritis.
- A. Which symptom is expected in a client with rheumatoid arthritis?
- B. Morning stiffness lasting over 30 minutes.
- C. Pain that worsens with activity.
- D. Asymmetrical joint involvement.
- E. Rapid onset of symptoms.
Correct Answer: A
Rationale: Morning stiffness lasting over 30 minutes is a hallmark of rheumatoid arthritis due to joint inflammation. Pain improves with activity, joints are symmetrically affected, and onset is gradual.
A woman with chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. Her vital signs are: BP 162/100, pulse 78, respirations 30 and labored with wheezing. The nurse should question which of the following orders?
- A. Theophylline (Somophyllin) 0.7 mg/kg/hr IV.
- B. Tetracycline hydrochloride (Sumycin) 250 mg IM qd.
- C. Ipratropium bromide (Atrovent) inhaler 2 inhalations qid.
- D. Propranolol hydrochloride (Inderal) 40 mg PO bid.
Correct Answer: D
Rationale: Propranolol, a non-selective beta-blocker, can cause bronchoconstriction, worsening COPD. Options A, B, and C are appropriate: theophylline bronchodilates, tetracycline treats infections, and ipratropium reduces bronchospasm.
The nurse is caring for a client who had a subtotal thyroidectomy yesterday. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a sore throat when I swallow.
- B. My legs feel cramped and tingly.
- C. I feel like my heart is skipping beats.
- D. I feel sleepy all the time.
Correct Answer: B
Rationale: Muscle cramps and tingling in the legs post-thyroidectomy suggest hypocalcemia, a serious complication due to possible parathyroid gland damage, which regulates calcium. This requires immediate assessment and intervention. Options A, C, and D are less urgent: sore throat is expected, palpitations may indicate hyperthyroidism, and sleepiness is nonspecific.