Nokea
The school nurse suspects that a third grade child might have attention deficit hyperactivity disorder (ADHD). Prior to referring the child for further evaluation, the nurse should
- A. Observe the child's behavior on at least 2 occasions
- B. Consult with the teacher about how to control impulsivity
- C. Compile a history of behavior patterns and developmental accomplishments
- D. Compare the child's behavior with classic signs and symptoms
Correct Answer: C
Rationale: Compile a history of behavior patterns and developmental accomplishments. A comprehensive history is essential for accurate ADHD diagnosis.
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A client with hyperkalemia is to receive an infusion of $250 \mathrm{~mL}$ of $20% glucose with 20 units of regular insulin. The rationale for this therapy is:
- A. Potassium elimination is enhanced.
- B. Potassium binds with the glucose and is excreted by the kidneys.
- C. Glucose uptake by the cell drives the potassium into the cell.
- D. Insulin lowers the potassium by lowering blood glucose.
Correct Answer: C
Rationale: Insulin facilitates glucose uptake by cells, which drives potassium into cells, lowering serum potassium levels in hyperkalemia.
Because a client is scheduled for a liver biopsy, the nurse should check to be sure that which laboratory test results have been received?
- A. Serum electrolytes
- B. Prothrombin time
- C. CBC with differential
- D. Serum creatinine
Correct Answer: B
Rationale: Liver biopsy carries a risk of bleeding due to the liver's vascular nature. Prothrombin time assesses clotting ability, critical to ensure the client can safely undergo the procedure without excessive bleeding risk. Electrolytes, CBC, and creatinine are less directly related to bleeding risk.
The LPN/LVN is to assist the school nurse in scoliosis screening. What instructions should be given to the students?
- A. Wear a bathing suit under your clothes on the examination day.
- B. Bring a urine sample to school.
- C. Do not wash your hair the night before the exam.
- D. Wash your feet well the morning of the exam.
Correct Answer: A
Rationale: A bathing suit allows easy spinal visualization during scoliosis screening, ensuring modesty and efficiency.
A patient has been ordered to get Klonapin for the first time. Which of the following side effects is not associated with Klonapin?
- A. Drowsiness
- B. Ataxia
- C. Salivation elevated
- D. Diplopia
Correct Answer: D
Rationale: A-C are associated side effects of Klonapin.
The practical nurse assists in the care of a client who was admitted in a state of acute psychosis after ingesting recreational substances. The parents ask the nurse if the client will develop schizophrenia. Which response by the nurse is appropriate?
- A. I know it must be terrible to see your child like this, but your child will be fine within a few days.
- B. It is important to understand that most people have permanent adverse effects after an episode like this.
- C. We cannot predict whether your child will develop schizophrenia; close observation is required to determine the cause of psychosis.
- D. Your child would be fine right now if they had not taken these drugs. We will need to do some additional testing
Correct Answer: C
Rationale: Schizophrenia risk cannot be predicted from a single episode; observation is needed. Reassurance , permanent effects , and blame are inaccurate.