Nokea
The nurse is screening an eight-month-old girl in a well-baby clinic. The nurse would be MOST concerned if the infant's mother made which of the following statements?
- A. My daughter has almost doubled her birth weight.
- B. When I walk in the room my child smiles at me.
- C. When she is around her grandpa, my child cries.
- D. My daughter can't quite say Mama yet.
Correct Answer: A
Rationale: An eight-month-old should have doubled birth weight by 5–6 months; 'almost doubled' suggests growth delay, requiring evaluation. Options B, C, and D are normal behaviors.
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During a first aid class, the nurse instructs clients on the emergency care of second-degree burns.
- A. Which intervention for second-degree burns of the chest and arms best prevents infection?
- B. Wash the burn with an antiseptic soap and water.
- C. Remove clothing and wrap the victim in a clean sheet.
- D. Leave the blisters intact and apply an ointment.
- E. Take no action until the victim arrives in a burn unit.
Correct Answer: B
Rationale: Removing clothing and wrapping the victim in a clean sheet minimizes contamination and prevents infection in an emergency setting. Soap, ointments, or delaying action increase infection risk by introducing irritants or leaving the wound exposed.
A client with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. The most therapeutic response by the nurse to his refusal is
- A. You need to take your medicine, this is how you get well.
- B. If you refuse your medicine, we'll just have to give you a shot.
- C. What is it about the medicine that you don't like?
- D. I can see that you are uncomfortable right now, I'll wait until tomorrow.
Correct Answer: C
Rationale: What is it about the medicine that you don't like? This fosters trust and open communication, encouraging the client to express concerns.
An adult is admitted with pernicious anemia. Which factor in the client's history is most likely related to the development of pernicious anemia?
- A. The client had an upper gastrointestinal (GI) bleed a year ago.
- B. The client had chemotherapy three months ago.
- C. The client had a gastrectomy six months ago.
- D. The client's mother had iron deficiency anemia
Correct Answer: C
Rationale: Gastrectomy removes the stomach's intrinsic factor-producing cells, leading to vitamin B12 malabsorption, a primary cause of pernicious anemia.
A 23-year-old man with Addison's disease comes to the health clinic. The nurse should expect the client to report that his skin has become
- A. darker and more pigmented.
- B. ruddy and oily.
- C. puffy and scaly.
- D. pale and dry.
Correct Answer: A
Rationale: increase in melanocyte-stimulating hormone results in 'eternal tan'
The preoperative client is from a different country and tells the nurse that his family will be coming for a prayer service. Eighteen persons arrive and start chanting in the client's semiprivate room. What is the best response for the nurse?
- A. Explain that visitors are limited to two per client
- B. Ask the client's roommate if he/she objects to so many persons in the room
- C. Ignore the large number of people and the chanting
- D. Arrange for the group to go to the conference room or the chapel
Correct Answer: D
Rationale: Arranging for a private space respects cultural practices while minimizing disruption to the roommate, balancing sensitivity and practicality.