Nokea
The nurse observes a 2 1/2-year-old toddler in the waiting room. Based on expected child development, the nurse expects to see the child engaged in which type of play?
- A. playing alone, with no interaction with other children
- B. playing cooperatively in a single-sex group
- C. playing parallel to other children, but not playing together
- D. playing and interacting cooperatively in a mixed-sex group
Correct Answer: C
Rationale: Toddlers (2-3 years) engage in parallel play, playing alongside but not cooperatively with others, due to developing social skills.
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A client's wife states that her elderly husband has begun to slightly slur his words and drop word endings, he has become increasingly withdrawn socially, and he is irritable, accusing her of talking behind his back and whispering at him. The nurse suspects that the client should be initially evaluated for which of the following?
- A. Depression.
- B. Alzheimer's disease.
- C. Hearing loss.
- D. Stroke.
Correct Answer: C
Rationale: Slurred speech, social withdrawal, and irritability with accusations of whispering suggest hearing loss (C), which can cause communication difficulties and paranoia. Depression (A), Alzheimer's (B), and stroke (D) are less likely to present with this specific combination.
A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:
- A. Checking for cervical dilation
- B. Placing the client in a supine position
- C. Checking the client's blood pressure
- D. Obtaining a fetal heart rate
Correct Answer: C
Rationale: Epidural anesthesia can cause hypotension, making blood pressure monitoring a priority.
The nurse has an order for medication to be administered intrathecally. The nurse is aware that medications will be administered by which method?
- A. Intravenously
- B. Rectally
- C. Intramuscularly
- D. Into the cerebrospinal fluid
Correct Answer: D
Rationale: Intrathecal administration involves delivering medication directly into the cerebrospinal fluid, typically via a spinal injection, to target the central nervous system effectively.
A client scheduled for a carotid endarterectomy requires insertion of an intra-arterial blood pressure-monitoring device. The nurse plans to perform the Allen test. Which observation indicates patency of the ulnar artery?
- A. Blanching of the hand on compression and release of the ulnar artery
- B. Muscular twitching of the bicep muscle with use of a tourniquet at the wrist
- C. Hand turning pink after the nurse releases the pressure on the ulnar artery
- D. Flexion of the wrist when tapping the ulnar artery with a reflex hammer
Correct Answer: C
Rationale: The Allen test assesses collateral circulation. The hand turning pink after releasing ulnar artery pressure indicates patency, ensuring adequate blood flow if the radial artery is cannulated.
The home health nurse is visiting a client who plans to deliver her baby at home. Which statement by the client indicates an understanding regarding screening for phenylketonuria (PKU)?
- A. I will need to take the baby to the clinic within 24 hours of delivery to have blood drawn.
- B. I will need to schedule a home visit for PKU screening when the baby is 3 days old.
- C. I will remind the midwife to save a specimen of cord blood for the PKU test.
- D. I will have the PKU test done when I take her for her first immunizations.
Correct Answer: B
Rationale: PKU screening is typically performed at 2-3 days of age to ensure accurate results, as earlier testing may yield false negatives.