Nokea
Which of the following components is associated with hypertonic dehydration?
- A. Plasma sodium levels above 150 mEq/L
- B. Fluid moves from extracellular space to intracellular space
- C. Water loss is greater than electrolyte loss
- D. Physical signs and symptoms are grossly apparent
Correct Answer: C
Rationale: The correct answer is 'Water loss is greater than electrolyte loss.' In hypertonic dehydration, there is a higher loss of water compared to electrolytes, leading to elevated concentrations of electrolytes in the body. This condition is characterized by plasma sodium levels above 150 mEq/L. As water moves from the extracellular space to the intracellular space, it results in cellular dehydration. Choice A is incorrect because the plasma sodium levels associated with hypertonic dehydration are typically above 150 mEq/L, not between 130 and 150 mEq/L. Choice B is incorrect as fluid moves from the extracellular space to the intracellular space in hypertonic dehydration. Choice D is incorrect because physical signs and symptoms may not always be grossly apparent in hypertonic dehydration.
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When a mother is inquiring about her child's ability to potty train, what is the most critical aspect of toilet training?
- A. The age of the child
- B. The child's ability to understand instructions
- C. The overall mental and physical abilities of the child
- D. Consistent attempts with positive reinforcement
Correct Answer: C
Rationale: The most critical aspect of toilet training is the overall mental and physical abilities of the child. While age can play a role, it is not the sole determining factor. Understanding instructions is important but may not be the most critical aspect. Consistent attempts with positive reinforcement can be helpful, but without considering the child's abilities, it may not lead to successful potty training.
While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs?
- A. "I want to protect my child from any falls."?
- B. "I will set limits on exploring the house."?
- C. "I understand the need to use those new skills."?
- D. "I intend to keep control over our child."?
Correct Answer: C
Rationale: The correct answer is: "I understand the need to use those new skills."? This response indicates that the mother recognizes the importance of allowing the toddler to practice and develop new skills, supporting autonomy and exploration. Setting limits, protecting from falls, and intending to keep control go against the toddler's developmental needs. Toddlers at this stage require opportunities to explore, practice new skills, and gain independence to foster healthy development.
A client must use a non-rebreathing oxygen mask. Which of the following statements is true regarding this type of mask?
- A. A non-rebreather can provide an FiO2 of 40%.
- B. A client should breathe through his or her mouth when using a non-rebreather.
- C. A non-rebreather offers a reservoir from which the client inhales.
- D. The mask of a non-rebreather should be changed every 3 hours.
Correct Answer: A
Rationale: A non-rebreather mask is used for supplemental oxygen delivery for clients experiencing breathing difficulties. The non-rebreather mask includes a one-way valve that allows exhaled air to escape, preventing the rebreathing of carbon dioxide. The client inhales oxygenated air from a reservoir bag attached to the mask, providing high-concentration oxygen therapy. A non-rebreather mask can deliver FiO2 levels of up to 90%, making it an effective intervention for clients requiring high oxygen concentrations. Therefore, the statement that 'A non-rebreather can provide an FiO2 of 40%' is correct. Choices B, C, and D are incorrect because clients should breathe through their nose and mouth, the mask offers a reservoir for inhaling oxygen, and the mask should be assessed and potentially replaced if soiled or damaged, not routinely changed every 3 hours.
The client is receiving discharge teaching seven (7) days post myocardial infarction and inquires why he must wait six (6) weeks before engaging in sexual intercourse. What is the best response by the nurse to this question?
- A. "You need to regain your strength before attempting such exertion."?
- B. "When you can climb 2 flights of stairs without problems, it is generally safe."?
- C. "Have a glass of wine to relax you, then you can try to have sex."?
- D. "If you can maintain an active walking program, you will have less risk."?
Correct Answer: B
Rationale: Following a myocardial infarction, there is a risk of cardiac rupture at the site of the infarction for approximately six (6) weeks until scar tissue forms. The advice to wait until the client can climb two flights of stairs without issues is common among healthcare providers as it indicates an adequate level of physical exertion tolerance and suggests a lower risk of complications during sexual activity. Choice A is not specific to the recovery timeline related to sexual activity post-myocardial infarction. Choice C is inappropriate as alcohol consumption should not be recommended before sexual activity. Choice D, though promoting an active lifestyle, does not directly address the safety concerns related to sexual intercourse post-myocardial infarction.
The client has a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend:
- A. Isometric
- B. Range of motion
- C. Aerobic
- D. Isotonic
Correct Answer: D
Rationale: The nurse should recommend isometric exercises for the muscles of the casted extremity. Isometric exercises involve contracting and relaxing muscles without moving the affected part. This type of exercise helps maintain muscle strength without moving the joint, which is important for clients with immobilized extremities. Range of motion exercises involve moving the joint through its full range of motion, which may not be suitable for a client with a long leg cast. Aerobic exercises focus on increasing cardiovascular endurance and may not be appropriate for a client with a casted extremity. Isotonic exercises involve muscle contractions with movement, which may not be safe for the affected extremity in a cast.