Nokea
The nurse is teaching parents of an infant about introduction of solid food to their baby. What is the first food they can add to the diet?
- A. Vegetables
- B. Cereal
- C. Fruit
- D. Meats
Correct Answer: B
Rationale: Cereal is usually introduced first because it is well tolerated, easy to digest, and contains iron.
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A 56-year-old man is visiting the doctor for the first time in seven years for treatment for an infected finger. The office nurse wants him to make an appointment for a physical. The nurse knows that he does not understand the importance of a physical when he makes which statement?
- A. I know my blood sugar and weight should be monitored.'
- B. I am healthy. If I wasn't, I'd have some problems.'
- C. I don't smoke and I exercise daily.'
- D. I understand that checking my blood pressure is important.'
Correct Answer: B
Rationale: Assuming health without symptoms dismisses the need for preventive screenings, indicating a lack of understanding of physicals.
An adult is admitted with probable pulmonary tuberculosis. Which findings would the nurse expect to be present in this client? Select all that apply.
- A. High fevers in the morning
- B. Cough
- C. Bloody sputum
- D. Night sweats
- E. Weight gain
- F. Malaise
Correct Answer: B,C,D,F
Rationale: Tuberculosis causes chronic cough, hemoptysis (bloody sputum), night sweats, and malaise due to systemic infection. Fevers are typically low-grade and nocturnal, and weight loss, not gain, is common.
A client with a diagnosis of a ruptured lumbar disc.
The nurse should anticipate which of the following in assessing a client with a diagnosis of a ruptured lumbar disc?
- A. Sensation loss in an upper extremity.
- B. Clonic jerks in the affected foot.
- C. Paresthesia in the affected leg.
- D. Chorea in the upper and lower extremities.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) results from cervical lesions (2) can occur in a person who has been paralyzed from a spinal cord injury (3) correct-lumbar lesions can cause paresthesia, pain, muscle weakness, and atrophy in the lower extremities (4) is a sign of Huntington chorea, resulting from atrophy of parts of the brain
The nurse is assessing the client's abdomen. Which should the nurse do first?
- A. Auscultate
- B. Percuss
- C. Inspect
- D. Palpate
Correct Answer: C
Rationale: Abdominal assessment begins with inspection to observe for visible abnormalities, followed by auscultation, percussion, and palpation to avoid altering bowel sounds.
The nurse is caring for a client with a history of polycystic kidney disease.
- A. Which symptom is expected in a client with polycystic kidney disease?
- B. Chest pain and dyspnea.
- C. Flank pain and hematuria.
- D. Weight loss and fever.
- E. Numbness in the extremities.
Correct Answer: B
Rationale: Flank pain and hematuria are common in polycystic kidney disease due to cyst pressure and rupture. Chest pain, weight loss, and numbness are unrelated.