Nokea
These facts are true regarding the developmental stage of preschool children EXCEPT
- A. handedness is achieved by 3 years of age
- B. boys are usually later than girls in achieving bladder control
- C. knowing gender by 4 years
- D. musturbation
Correct Answer: D
Rationale: Musturbation is not a recognized developmental milestone.
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A client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:
- A. E-rosette immunofluorescence
- B. Enzyme-linked immunosorbent assay
- C. Quantification of T-lymphocytes (ELISA)
- D. Western blot test with ELISA
Correct Answer: D
Rationale: The confirmatory test for HIV infection is a Western blot test. However, before a Western blot test is conducted, an initial screening test with high sensitivity, such as the enzyme-linked immunosorbent assay (ELISA), is typically performed. ELISA is used to detect the presence of HIV antibodies in the blood. If the ELISA test is positive, a Western blot test is then performed to confirm the presence of specific HIV antibodies. The Western blot test is a more specific test for HIV antibodies and is used to confirm the diagnosis. Therefore, in this case, the physician would most likely order a Western blot test following a positive ELISA test to confirm the client's HIV infection.
Nurse Jeremy is evaluating a client's fluid intake and output record. Fluid intake and urine output should relate in which way?
- A. Fluid intake should be double the urine output.
- B. Fluid intake should be approximately equal to the urine output.
- C. Fluid intake should be half the urine output.
- D. Fluid intake should be inversely proportional to the urine output.
Correct Answer: B
Rationale: The principle of fluid balance in the body dictates that fluid intake should be approximately equal to the urine output, under normal circumstances. This balance ensures that the body maintains proper hydration levels and that the kidneys are functioning effectively in filtering and excreting waste products. Significant deviations between fluid intake and urine output can indicate potential issues with hydration status or kidney function, making it essential for healthcare professionals like Nurse Jeremy to closely monitor and evaluate these values.
A 13-year-old boy is hospitalized for a femur fracture after being hit by a car while racing bikes. The parents are concerned about his judgment. The nurse should tell the parents that this behavior is:
- A. Typical of young teens.
- B. Related to hormonal surges during adolescence.
- C. An isolated incident that will not likely happen again.
- D. Related to underdeveloped judgment and impulse control in adolescence.
Correct Answer: D
Rationale: The adolescent brain is still developing, which can lead to poor judgment and impulsive behavior.
An adult suffered a diving accident and is being brought in by an ambulance intubated and on backboard with a cervical collar. What is the first action the nurse would take on arrival in the hospital?
- A. Take the client vital signs
- B. Insert a large bore IV line
- C. Check the lungs for equal breath sounds bilaterally
- D. Perform a neurologic check using the Glasgow scale
Correct Answer: B
Rationale: The first action the nurse should take upon the arrival of the adult who suffered a diving accident and is intubated and on a backboard with a cervical collar is to insert a large bore IV line. This is a priority because the person may require urgent fluid resuscitation or medication administration, and having IV access is crucial for immediate intervention in trauma cases. After establishing IV access, other assessments such as vital signs, lung sounds, and neurological checks can follow.
Which is the most commonly used method in completed suicides?
- A. Firearms
- B. Drug overdose
- C. Self-inflected laceration
- D. Carbon monoxide poisoning
Correct Answer: A
Rationale: Firearms are the most commonly used method in completed suicides, accounting for nearly 50% of all suicide deaths in the United States. Firearms are particularly lethal and result in a higher success rate compared to other methods. The quick and irreversible nature of firearm suicides contributes to their high prevalence. Additionally, the easy access to firearms in many households increases the likelihood of their use in suicide attempts.