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A five-year-old boy in the playroom.
The school nurse observes a group of preschool children in the playroom. The nurse recognizes which of the following activities as appropriate behavior for a five-year-old boy?
- A. The boy plays with a large truck with another child.
- B. The boy talks on a toy telephone and imitates his father.
- C. The boy works on a puzzle with several other children.
- D. The boy holds and cuddles a large stuffed animal.
Correct Answer: B
Rationale: Strategy: Picture the child. (1) play begins to be cooperative at this age (2) correct-imitative behavior seen at this age (3) too advanced for this age (4) too regressed for this age
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The nurse is teaching a client with a new diagnosis of gout about allopurinol (Zyloprim). Which of the following statements by the client indicates a need for further teaching?
- A. I should drink plenty of water while taking this medication.
- B. I should report a rash to my doctor.
- C. I should take this medication with food.
- D. I should stop this medication if my gout attacks stop.
Correct Answer: D
Rationale: Stopping allopurinol when gout attacks stop is incorrect, as it is used long-term to prevent uric acid buildup. Options A, B, and C are correct: water prevents kidney stones, rash may indicate hypersensitivity, and food reduces GI upset.
The nurse is caring for a client who is postoperative day 1 after a thyroidectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Heart rate of 80 bpm.
- D. Calcium level of 9.0 mg/dL.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-thyroidectomy complication. Options A, C, and D are normal or expected.
The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Some increase in the serum hemoglobin
- D. A little decrease in the serum potassium
Correct Answer: B
Rationale: Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss of acid and lead to metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse.
An older man is being prepared for discharge after treatment for dehydration.
Which of the following statements, if made by the patient to the nurse, indicates that further teaching is needed?
- A. I should weigh myself daily.'
- B. I should drink fluids throughout the day.'
- C. I can use a measuring cup to find out how much I drink during the day.'
- D. I should let my doctor know if I get dizzy when I change positions.'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to dehydration. Be careful, this is a negative question. (1) correct-would only indicate overhydration, not response to dehydration (2) will help prevent recurrence of dehydration, should force fluids to 3,000 cc/day (3) would give good indication of total intake (4) would indicate postural hypotension resulting from volume deficit
The nurse is to administer Lanoxin(digoxin) elixir to a 6-month old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100 . The nurse should:
- A. Record the heart rate and call the physician.
- B. Record the heart rate and administer the medication.
- C. Administer the medication and recheck the heart rate in 15 minutes.
- D. Hold the medication and recheck the heart rate in 30 minutes.
Correct Answer: B
Rationale: A pulse of 100 in a 6-month-old is normal (80-150 bpm), so the nurse should administer digoxin . Calling the physician or holding the dose is unnecessary. Rechecking later is not standard.