Nokea
Which of the following describes the language development of a two-year-old?
- A. Doesn't understand yes and no
- B. Understands the meaning of all words
- C. Can combine three or four words
- D. Repeatedly asks 'why?'
Correct Answer: C
Rationale: A two-year-old typically can combine three or four words to form simple sentences (e.g., 'Me want milk'). They understand basic concepts like 'yes' and 'no,' but not all words. Repeatedly asking 'why?' is more common in older preschoolers.
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The nurse is performing an assessment on a client with a suspected diagnosis of cataracts. The chief complaint is likely to be:
- A. Eye pain with movement
- B. Cloudy vision
- C. Flashing lights
- D. Eye redness
Correct Answer: B
Rationale: Cataracts cause cloudy or blurry vision due to lens opacity. Eye pain, flashing lights, and redness are more associated with other conditions like glaucoma or retinal issues.
A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include:
- A. Monitoring the chest tubes
- B. Positioning the client on the right side
- C. Positioning the client in semi-Fowler position with a pillow under the shoulder and back
- D. Monitoring the right lung for an increase in rales
Correct Answer: D
Rationale: Monitoring the right lung for an increase in rales is essential to detect early signs of fluid accumulation or infection in the remaining lung.
The nurse is caring for a client with a history of a fractured humerus who is in a sling. The client complains of numbness. The nurse should:
- A. Apply ice to the arm
- B. Elevate the arm
- C. Notify the physician immediately
- D. Massage the arm
Correct Answer: C
Rationale: Numbness in a slung humerus suggests neurovascular compromise, requiring immediate physician notification. Ice, elevation, and massage are insufficient or contraindicated.
A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for the nurse to remember which of the following principles?
- A. The parts of a system are only minimally related.
- B. Dysfunction in one part affects every other part.
- C. A family system has no boundaries.
- D. Healthy families are enmeshed.
Correct Answer: B
Rationale: Any change in any part of the system affects all other parts.
The client is admitted with a diagnosis of gestational hypertension. Which vital sign change is most concerning?
- A. Blood pressure of 160/110
- B. Heart rate of 90 bpm
- C. Respiratory rate of 20 breaths per minute
- D. Temperature of 98.6°F
Correct Answer: A
Rationale: A blood pressure of 160/110 indicates severe gestational hypertension increasing the risk of complications like stroke or eclampsia and requires immediate intervention. The other vital signs are normal.