Nokea
The nurse is speaking with the parent of a toddler who believes the child has a hearing deficit. Which findings support this suspected diagnosis? Select all that apply.
- A. Behavior appears withdrawn
- B. Inintelligible speech began at age 12 months
- C. Monotone speech
- D. Seems attentive, nods, and smiles when given directions
- E. Speaks with a loud voice
Correct Answer: A,C,E
Rationale: Signs of hearing deficit in a toddler include withdrawn behavior , monotone speech , and loud speech due to inability to modulate voice. Inintelligible speech at 12 months is normal, and attentiveness suggests intact hearing.
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A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority?
- A. Maintaining proper body alignment
- B. Frequent neurovascular assessments of the affected leg
- C. Inspection of pin sites for evidence of drainage or inflammation
- D. Applying an over-bed trapeze to assist the client with movement in bed
Correct Answer: B
Rationale: The most important activity for the nurse is to assess neurovascular status. Compartment syndrome is a serious complication of fractures. Prompt recognition of this neurovascular problem and early intervention may prevent permanent limb damage.
Four clients arrive in the urgent care clinic. Which does the nurse anticipate to be the priority for intervention?
- A. Child who is confused and irritable and whose parent claims 2 glyburide pills are missing
- B. Child with an abscess on the buttock that is red, swollen, and warm to the touch
- C. Child with immune thrombocytopenia who fell off a bike and reports shoulder pain
- D. Child with low-grade fever, barking cough, and runny nose who has mild retractions
Correct Answer: A
Rationale: The child who is confused and irritable with missing glyburide pills suggests a potential hypoglycemic emergency due to sulfonylurea overdose, which requires immediate intervention to prevent severe complications like seizures or coma.
The nurse is caring for an adult who is receiving diphenoxylate hydrochloride with atropine sulfate (Lomotil) qid. What nursing assessment is essential while the client is receiving this medication?
- A. Monitor blood pressure hourly
- B. Assess respirations before administering drug
- C. Measure hourly urine output
- D. Do neuro checks every two hours
Correct Answer: B
Rationale: Lomotil can cause respiratory depression due to its opioid component, requiring respiratory assessment before administration.
The nurse is reviewing new medication prescriptions for a client with asthma and nasal polyps. The nurse should clarify the prescription for
- A. ibuprofen
- B. vitamin D
- C. albuterol
- D. montelukast
Correct Answer: A
Rationale: Ibuprofen should be clarified in asthma with nasal polyps due to risk of aspirin-exacerbated respiratory disease. Vitamin D , albuterol , and montelukast are safe.
The client has contact dermatitis from poison ivy. Which statement, if made by the client, indicates that he understands how to care for his condition?
- A. A hot bath should make the itching go away.'
- B. I will use a good strong soap when I wash the affected areas.'
- C. A cool wet cloth to the area should help.'
- D. Wearing wool socks will help my itchy feet.'
Correct Answer: C
Rationale: A cool wet cloth soothes itching and inflammation in contact dermatitis. Hot baths, strong soaps, or wool exacerbate irritation.