Nokea
Which of the following describes the proximodistal development in the infant?
- A. The infant is able to raise his head before he is able to sit.
- B. The infant can control movements of his arms before he can control movements of his fingers.
- C. The infant responds to pain with his whole body before he can localize pain.
- D. The infant is able to make rudimentary vocalizations before using spoken words.
Correct Answer: B
Rationale: Proximodistal development refers to motor control progressing from the center of the body outward, meaning infants gain control of larger muscles (arms) before finer muscles (fingers).
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A client is diagnosed with bipolar disorder and is in a manic phase with combative behavior.
An INITIAL nursing priority is to
- A. provide adequate hygiene and nutrition.
- B. decrease environmental stimuli.
- C. slowly involve the client in unit activities.
- D. administer and monitor sedative and mood-stabilizing medications.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) is very important to ensure adequate hygiene and nutrition, but behavioral control and client/milieu safety are an initial priority (2) decreasing environmental stimulation is an additional strategy that, when utilized in conjunction with psychopharmacologic intervention, can reduce hyperactivity and aggressive acts; just decreasing environmental stimulation will not diminish client's internal sense of agitation and aggression (3) this action is inappropriate at this time (4) correct-is most important to gain control with a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention with both sedative medications and mood-stabilizing agents
A client scheduled for a Nissen repair for a hiatal hernia is being instructed preoperatively to use the incentive spirometer. The nurse determines that the client has understood the teaching when the client states:
- A. These exercises will help to decrease my pain.
- B. I should use this device once a day.
- C. If I use this device, it will help in preventing pneumonia.
- D. I should do these breathing techniques while lying down flat in bed.
Correct Answer: C
Rationale: Incentive spirometry's purpose is to prevent or treat atelectasis, which can lead to pneumonia. Answer A is a false statement, so it is incorrect. Answer B is incorrect because the timing is not as often as it should be. Answer D is wrong because it is best done sitting upright.
A client receiving amphotericin B (Fungizone) 1 mg in 250 cc of 5% dextrose in water IV over a 2-hour period.
The nurse should be MOST concerned if which of the following was observed?
- A. BUN 7.2 mg/dL, creatinine 0.5 mg/dL.
- B. BP 90/60, complaints of fever and chills.
- C. Complaints of burning on urination, thirst, and dizziness.
- D. AST (SGOT) 12 U/L, ALT (SGPT) 14 U/L, total bilirubin 0.2 mg/dL.
Correct Answer: B
Rationale: Strategy: 'MOST concerned' indicates an untoward effect of the medication. (1) normal results, causes renal toxicity, BUN and creatine would be elevated, normal BUN 7-18 mg/dL, normal creatine 0.6-1.2 mg/dL (2) correct-monitor vital signs every 30 min (3) not side effect of medication (4) normal AST (formerly SGOT) 8-20 U/L, normal ALT (formerly SGPT) 8-20 U/L, normal bilirubin 0.1-1.0 mg/dL, may cause elevation, check liver function studies weekly, notify physician if elevated
Which of the following lab values might the nurse expect to see in a client with Addison's disease?
- A. WBC 10,000
- B. BUN 22
- C. $\mathrm{K}+3.5 \mathrm{mEq} / \mathrm{L}$
- D. $\mathrm{Na}+142 \mathrm{mEq} / \mathrm{L}$
Correct Answer: C
Rationale: Addison's disease causes hyperkalemia (elevated potassium, not 3.5 mEq/L, which is normal) and hyponatremia due to adrenal insufficiency.
Which of the actions suggested to the registered nurse (RN) by the practical nurse (PN) during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?
- A. Measure head circumference
- B. Place in airborne isolation
- C. Provide passive range of motion
- D. Provide an over-the-crib protective top
Correct Answer: A
Rationale: Measure head circumference. This monitors for complications like hydrocephalus in meningitis.