Nokea
The nurse is preparing to receive a client from admitting with tumor lysis syndrome (TLS). Which of the following would the nurse expect to find on the laboratory and patient history sections of the chart?
- A. Low blood pressure
- B. Hyperactivity
- C. Hyperkalemia
- D. Hyperuricemia
- E. Mental changes
Correct Answer: A,C,D,E
Rationale: TLS causes hyperkalemia (C), hyperuricemia (D), and mental changes (E) due to electrolyte imbalances and low blood pressure (A) from fluid shifts. Hyperactivity (B) is not typical.
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Which play activity is best suited to the gross motor skills of a toddler?
- A. Coloring book and crayons
- B. Ball
- C. Building cubes
- D. Swing set
Correct Answer: B
Rationale: Playing with a ball encourages gross motor skills like kicking, throwing, and running, suitable for a toddler's developmental stage. The other activities focus more on fine motor skills or require advanced coordination.
A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:
- A. Withholding all morning medications
- B. Ordering a CBC and CPK
- C. Administering prescribed anti-Parkinsonian medication
- D. Transferring the client to a medical unit
Correct Answer: D
Rationale: Muscle rigidity and fever suggest neuroleptic malignant syndrome (NMS), a life-threatening reaction to olanzapine. Immediate transfer to a medical unit for urgent treatment is critical.
A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best auscultated just:
- A. Below the umbilicus toward left side of mother's abdomen
- B. Below the umbilicus toward right side of mother's abdomen
- C. At the umbilicus
- D. Above the umbilicus to the left side of mother's abdomen
Correct Answer: A
Rationale: In LOA, the fetus's back is on the mother's left anterior side, so fetal heart sounds are best heard below the umbilicus on the left.
The nurse is caring for a client with a diagnosis of oligohydramnios. Which finding is most likely to be present?
- A. Decreased fetal movement
- B. Increased fetal heart rate
- C. Uterine size larger than expected
- D. Fetal macrosomia
Correct Answer: A
Rationale: Oligohydramnios (low amniotic fluid) can restrict fetal movement due to limited space making decreased fetal movement a likely finding. Fetal heart rate may be normal or show distress uterine size is smaller and macrosomia is unrelated.
The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should:
- A. Give her a small soft blanket to hold
- B. Give her good perineal care after each diaper change
- C. Leave the door open to her room
- D. Pick her up when she cries
Correct Answer: D
Rationale: A soft blanket may be comforting, but it is not directed toward developing a sense of trust. Good perineal care is important, but it is not directed toward developing a sense of trust. An infant with meningitis needs frequent attention, but leaving the door open does not foster trust. Consistently picking her up when she cries will help the child feel trust in her caregivers.