Nokea
The nurse is preparing to perform a physical examination on an 8 month-old who is sitting contentedly on his mother's lap. Which of the following should the nurse do first?
- A. Elicit reflexes
- B. Measure height and weight
- C. Auscultate heart and lungs
- D. Examine the ears
Correct Answer: C
Rationale: Auscultate heart and lungs. Performing this during a quiet moment ensures clear sound detection.
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The nurse is caring for a client with a history of schizophrenia who is experiencing auditory hallucinations. Which of the following interventions is MOST appropriate?
- A. Argue with the client about the reality of the voices.
- B. Encourage the client to listen to music with headphones.
- C. Instruct the client to ignore the voices completely.
- D. Administer an antipsychotic medication as ordered.
Correct Answer: B
Rationale: Listening to music with headphones can distract from auditory hallucinations, reducing their intensity. Arguing (A) increases agitation, ignoring voices (C) is ineffective, and administering medication (D) is appropriate but not the most immediate non-pharmacologic intervention.
The nurse is preparing to discharge a client who is receiving Nardil (phenelzine). The nurse should tell the client to:
- A. Wear protective clothing and sunglasses outside.
- B. Avoid medications containing pseudoephedrine.
- C. Drink six to eight glasses of water a day.
- D. Avoid foods that are high in purine.
Correct Answer: B
Rationale: Drug interactions between an MAOI and pseudoephedrine can result in hypertensive crisis. Answer A refers to the client receiving antipsychotic medications such as Thorazine, so it is incorrect. Answers C and D do not apply to MAOIs, so they are incorrect.
A 12-year-old male is brought to his primary care provider to determine whether sexual abuse has occurred. The mother states, 'Because there is no permanent physical damage, he does not need any more treatment.' The nurse's response should be based on which of the following pieces of information?
- A. Male victims of sexual abuse seldom have long-term psychological problems.
- B. Survivors of male sexual abuse might become confused about their sexual identity.
- C. Unless treated, all male sex abuse survivors grow up to abuse other children.
- D. All children who have been sexually abused have the same needs, regardless of gender.
Correct Answer: B
Rationale: Male sexual abuse survivors may experience confusion about sexual identity, necessitating psychological support. The other statements are incorrect: long-term issues are common, not all survivors become abusers, and needs vary by gender. Psychosocial Integrity
The nurse is assessing a client with a suspected fracture of the radius. Which of the following findings would support this diagnosis?
- A. Swelling and deformity at the wrist.
- B. Pain in the shoulder with movement.
- C. Numbness in the lower leg.
- D. Fever and joint stiffness.
Correct Answer: A
Rationale: A radius fracture typically causes swelling and deformity at the wrist due to bone disruption. Shoulder pain (B) suggests a proximal injury, leg numbness (C) is unrelated, and fever/stiffness (D) indicate infection or arthritis.
The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation?
- A. Chills
- B. Scant lochia rubra
- C. Thirst and fatigue
- D. Temperature of 100.2°F (37.9°C)
Correct Answer: B
Rationale: During the early postpartum period, lochia rubra should be moderate to significant. Scant lochia rubra suggests that large clots are blocking the lochial flow. After delivery, vasomotor changes may cause a shaking chill. Thirst, fatigue, and a temperature of up to 100.4°F (38°C) also are common at 24 hours postpartum.