Nokea
What would the nurse expect to see while assessing the growth of children during their school age years?
- A. Decreasing amounts of body fat and muscle mass
- B. Little change in body appearance from year to year
- C. Progressive height increase of 4 inches each year
- D. Yearly weight gain of about 5.5 pounds per year
Correct Answer: D
Rationale: School age children gain about 5.5 pounds each year and increase about 2 inches in height.
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A client just diagnosed with methicillin-resistant Staphylococcus aureus septic arthritis is receiving the first dose of IV vancomycin. Which finding is most concerning to the nurse?
- A. Diffuse muscle pain
- B. Flushing and pruritus
- C. Low blood pressure
- D. Wheezing and hives
Correct Answer: D
Rationale: Wheezing and hives (D) indicate a possible anaphylactic reaction, the most concerning finding. Muscle pain (A), flushing/pruritus (B), and low blood pressure (C) are less immediately life-threatening.
A client continually repeats phrases that others have just said. The nurse recognizes this behavior as
- A. Autistic
- B. Echopraxis
- C. Echolalia
- D. Catatonic
Correct Answer: C
Rationale: Echolalia is repeating words or phrases heard before, often seen in certain psychiatric or developmental conditions.
The nurse reviews the ECG of a client. Which prescribed medication should the nurse suspect as the cause of the ECG findings?
- A. Captopril
- B. Carvedilol
- C. Glipizide
- D. Levothyroxine
Correct Answer: D
Rationale: Levothyroxine (D) can cause arrhythmias, which may be reflected in ECG changes. Captopril (A), Carvedilol (B), and Glipizide (C) are less likely to cause significant ECG alterations.
Parents of a 6 month-old breast fed baby ask the nurse about increasing the baby's diet. Which of the following should be added first?
- A. Cereal
- B. Eggs
- C. Meat
- D. Juice
Correct Answer: A
Rationale: Cereal. Strained cereal is recommended as the first solid food for breastfed infants, per pediatric guidelines.
A client is being discharged after having a coronary artery bypass grafting x5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? Select all that apply.
- A. Report any itching, tingling, or numbness around your incisions
- B. Report any redness, swelling, warmth, or drainage from your incisions
- C. Soak incisions in the tub once a week, then clean with hydrogen peroxide and apply lotion
- D. Wash incisions daily with soap and water in the shower and gently pat them dry
- E. Wear an elastic compression hose on your legs and elevate them while sitting
Correct Answer: A, B, D
Rationale: Reporting sensory changes (A), signs of infection (B), and washing gently (D) promote healing. Soaking and peroxide (C) can disrupt healing, and compression hose (E) are not routinely needed.