Nokea
When teaching the guardian of a 12-year-old male client about manifestations of puberty, which of the following physical changes typically occurs first?
- A. Appearance of downy hair on the upper lip
- B. Hair growth in the axillae
- C. Enlargement of the testes and scrotum
- D. Deepening of the voice
Correct Answer: C
Rationale: During puberty in males, the first physical change that typically occurs is the enlargement of the testes and scrotum. This change is due to increased production of testosterone, which stimulates growth and development of the genital organs. The appearance of downy hair on the upper lip (Choice A) and hair growth in the axillae (Choice B) usually follow the enlargement of the testes and scrotum. Deepening of the voice (Choice D) is a later stage change that occurs during puberty as the larynx (voice box) grows and the vocal cords lengthen and thicken.
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A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
- A. Comatose, breathing unlabored
- B. Glasgow Coma Scale 8, respirations regular
- C. Appears to be sleeping, vital signs stable
- D. Glasgow Coma Scale 13, no ventilator required
Correct Answer: B
Rationale: A client with Guillain-Barre syndrome in a non-responsive state with stable vital signs and independent breathing would most accurately be described by a Glasgow Coma Scale of 8 with regular respirations. Choice A is incorrect as 'comatose' implies a deeper level of unconsciousness than described in the scenario. Choice C is incorrect as 'appears to be sleeping' is not an accurate description of a non-responsive state. Choice D is incorrect as a Glasgow Coma Scale of 13 indicates a higher level of consciousness than stated in the scenario.
A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?
- A. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back
- B. Pinch the skin on the back of the hand and observe for elasticity
- C. Assess the skin turgor on the abdomen by pinching the skin
- D. Check the skin turgor by pressing on the forearm and observing the rebound
Correct Answer: A
Rationale: To assess skin turgor, the nurse should grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. This method is preferred for older adults and in cases of significant fluid imbalance. Option B is incorrect as assessing skin turgor on the back of the hand is not the standard assessment site for skin turgor. Option C is incorrect as the abdomen is not the typical area for assessing skin turgor; the chest under the clavicle is a more accurate site. Option D is incorrect as pressing on the forearm is not the appropriate site for evaluating skin turgor; the chest under the clavicle is the recommended location for this assessment.
A healthcare professional is preparing information for a change-of-shift report. Which of the following information should the healthcare professional include in the report?
- A. Input and output measurements for the shift
- B. Blood pressure readings from the previous day
- C. Bone scan scheduled for today
- D. Medication regimen from the medication administration record
Correct Answer: D
Rationale: During a change-of-shift report, healthcare professionals should include the medication regimen from the medication administration record. This information ensures continuity of care and helps incoming staff understand the patient's medication needs and schedule. While input and output measurements, blood pressure readings, and scheduled procedures like a bone scan are important aspects of patient care, they may not be immediately relevant for the incoming shift. Focusing on medication details helps prevent errors and ensures the patient receives the correct medications at the right times.
A client is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?
- A. The client reports severe pain
- B. The client asks for a demonstration
- C. The client inquires about potential complications
- D. The client agrees to the procedure
Correct Answer: A
Rationale: The correct answer is A because severe pain can hinder the client's ability to participate effectively in learning. Pain can be distracting and may prevent the client from focusing on acquiring new information or skills. Choice B is incorrect because asking for a demonstration shows an interest in learning and readiness to understand the exercises. Choice C is incorrect as inquiring about potential complications indicates the client's engagement in understanding the procedure and its outcomes, demonstrating readiness to learn. Choice D is incorrect as agreeing to the procedure does not necessarily reflect a lack of readiness to learn. The client may still be open to receiving information about postoperative care, indicating a level of readiness to learn despite agreeing to the surgery.
The LPN/LVN mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive?
- A. 31 gtt/min.
- B. 62 gtt/min.
- C. 93 gtt/min.
- D. 124 gtt/min.
Correct Answer: D
Rationale: To calculate the drops per minute for the client, first, convert the weight from pounds to kilograms by dividing 182 by 2.2, which equals 82.72 kg. Then, calculate the dose in mcg/min by multiplying the weight in kg by the rate (82.72 kg * 5 mcg/kg/min = 413.6 mcg/min). Next, convert 50 mg to mcg (50 mg * 1000 = 50,000 mcg). Divide the total mcg (50,000 mcg) by the dose per minute (413.6 mcg/min) to get approximately 121 gtt/min. However, since the drip factor is 60 gtt/ml, the correct answer is 124 gtt/min, ensuring the accurate administration rate of the medication. Therefore, choice 'D' is the correct answer. Choices 'A', 'B', and 'C' are incorrect as they do not accurately reflect the calculated drops per minute based on the given information.