Nokea
The nurse should assess the child with nephrotic syndrome for which of the following? Select all that apply.
- A. Normal blood pressure.
- B. Generalized edema.
- C. Normal serum lipid levels.
- D. No red blood cells in the urine.
- E. Elevated streptococcal antibody titers.
Correct Answer: B,D
Rationale: Nephrotic syndrome is characterized by generalized edema and no red blood cells in the urine. Blood pressure may be elevated, serum lipids are typically high, and streptococcal antibodies are not typically associated.
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Which tool or scale would you use for a focused neurological assessment of your client?
- A. The Lazarus Cognitive Appraisal Scale
- B. The Hamilton Rating Scale
- C. The McGill Scale
- D. The Rancho Los Amigos Scale
Correct Answer: D
Rationale: The Rancho Los Amigos Scale is used for assessing levels of consciousness and cognitive recovery in patients with brain injuries, ideal for a focused neurological assessment.
Which of the following is considered an internal disaster?
- A. A tornado that has touched down on the healthcare facility
- B. A severe cyclone that has destroyed nearby homes
- C. A massive train accident that brings victims to your facility
- D. An act of bioterrorism in a nearby factory
Correct Answer: A
Rationale: An internal disaster is an event within the healthcare facility, such as a tornado directly affecting it, requiring internal emergency protocols.
A usually reliable interpreter called by the nurse to help communicate with a mother of a child who does not speak English and has brought her child in for a routine visit has yet to arrive in the clinic. The nurse has paged the interpreter several times. Which of the following should the nurse do next?
- A. Continue with the examination.
- B. Reschedule the infant's appointment for later in the week.
- C. Ask the mother to stay longer in the hope that the interpreter arrives.
- D. Page the interpreter one more time.
Correct Answer: B
Rationale: Rescheduling ensures effective communication with the interpreter, avoiding potential misunderstandings during the visit.
The nurse is caring for a client post-myocardial infarction. Which activity should the nurse encourage to promote recovery?
- A. Bed rest for 48 hours
- B. Light ambulation as tolerated
- C. Heavy lifting after 24 hours
- D. High-intensity exercise
Correct Answer: B
Rationale: Light ambulation as tolerated promotes circulation and prevents complications like deep vein thrombosis, while avoiding overexertion post-myocardial infarction.
The nurse should inform a client taking carbamazepine (Tegretol) that it can affect other medications in which of the following ways?
- A. It decreases the effects of oral anticoagulants
- B. It decreases the serum concentration of verapamil (Calan)
- C. It increases the serum concentration of other anticonvulsants
- D. It increases the effects of oral contraceptives
Correct Answer: A
Rationale: Carbamazepine induces liver enzymes, reducing the effects of oral anticoagulants like warfarin by increasing their metabolism. It does not typically affect verapamil, other anticonvulsants, or contraceptives in the ways described.