Nokea
The nurse performs an assessment of an 8-year-old girl diagnosed with scoliosis.
- A. Which observation is expected in an 8-year-old girl with scoliosis?
- B. The girl’s thoracic area is asymmetrical.
- C. The girl walks with a waddling gait.
- D. The girl’s lower legs are edematous.
- E. The girl has a protruding sternum.
Correct Answer: A
Rationale: Scoliosis causes lateral spinal curvature, leading to thoracic asymmetry. Waddling gait is associated with hip issues, edema with circulatory problems, and a protruding sternum with pectus carinatum, none of which are typical of scoliosis.
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The nurse is teaching a client with a new diagnosis of hyperthyroidism about methimazole (Tapazole). Which of the following statements by the client indicates a need for further teaching?
- A. I should report a sore throat to my doctor.
- B. I should take this medication with food.
- C. I should avoid eating iodized salt.
- D. I should stop this medication if I feel better.
Correct Answer: D
Rationale: Stopping methimazole when feeling better is incorrect, as hyperthyroidism requires prolonged treatment to achieve euthyroid status. Options A, B, and C are correct: sore throat may indicate agranulocytosis, food reduces GI upset, and avoiding iodized salt prevents thyroid stimulation.
The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group?
- A. Aerobic exercise classes
- B. Transportation for shopping trips
- C. Reminiscence groups
- D. Regularly scheduled social activities
Correct Answer: C
Rationale: Reminiscence groups. These support ego integrity by helping elderly clients find meaning in their lives, per Erikson's theory.
The nurse is providing home care. Which assessment finding would suggest to the nurse that the elderly client should be evaluated for abuse?
- A. The client says, 'My daughter takes some of my Social Security money. She says it's to pay for my food and medicine.'
- B. The client has several bruises on her arms and legs.
- C. The client says her family is mean because they hire someone to stay with her when they go out.
- D. The client has several bruises and circular marks that look like cigarette burns on her back.
Correct Answer: D
Rationale: Bruises and circular marks resembling cigarette burns strongly suggest physical abuse, requiring immediate evaluation. Unexplained bruises are concerning but less specific, and the other options may reflect misunderstanding or caregiving arrangements.
The nurse is caring for a person who has a nasogastric tube attached to drainage. Which complaint by the client needs to be reported to the charge nurse?
- A. Dry mouth
- B. Weak muscles
- C. Sore throat
- D. Irritated nose
Correct Answer: C
Rationale: A sore throat may indicate nasogastric tube complications like erosion or infection, requiring evaluation. Dry mouth, weakness, or nasal irritation are expected.
A client with schizophrenia is receiving Clozaril (clozapine) 150 mg twice a day. An adverse reaction to the medication is:
- A. Photosensitivity
- B. Extreme elevations in temperature
- C. Weight gain
- D. Elevated blood pressure
Correct Answer: C
Rationale: Weight gain is a common adverse reaction to clozapine, often requiring monitoring and lifestyle interventions.