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Which of the following is appropriate when developing a plan of care for promoting the development of a preschooler? Select all that apply.
- A. Providing anticipatory guidance for parents.
- B. Helping the parents understand their child's behavior.
- C. Identifying deviations from normal growth and development patterns.
- D. Determining the child's future development.
- E. Sending the child to a day care center.
Correct Answer: A,B,C
Rationale: Anticipatory guidance, understanding behavior, and identifying deviations support preschooler development. Predicting future development is not feasible, and daycare is not universally required.
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A primary concern of the hospitalized adolescent is:
- A. Respect for the need for privacy.
- B. Allowing parents to visit after hours.
- C. Wearing a hospital gown.
- D. The fear of loss of control when in pain.
Correct Answer: A
Rationale: Adolescents value autonomy and privacy, which is a primary concern during hospitalization, as it supports their developmental need for independence.
A primigravid client at 38 weeks' gestation reports decreased fetal movement. What is the nurse's first action?
- A. Perform a nonstress test.
- B. Notify the physician.
- C. Encourage the client to drink water.
- D. Auscultate fetal heart tones.
Correct Answer: D
Rationale: Auscultating fetal heart tones is the first step to assess fetal well-being in response to decreased movement, providing immediate data.
A client with a history of peptic ulcer disease is prescribed sucralfate (Carafate). The nurse should instruct the client to:
- A. Take the medication 1 hour before meals.
- B. Take the medication with meals.
- C. Take the medication at bedtime.
- D. Stop the medication if constipation occurs.
Correct Answer: A
Rationale: Sucralfate should be taken 1 hour before meals to coat the stomach lining and protect ulcers.
A normal, healthy infant is brought to the clinic for the first immunization against polio. The nurse should administer this vaccine by what route?
- A. Oral route.
- B. I.M. route.
- C. Subcutaneous route.
- D. Intradermal route.
Correct Answer: A
Rationale: The polio vaccine for infants is administered orally (OPV) in many regions, though inactivated polio vaccine (IPV) is given intramuscularly in some settings. Based on the options, oral is correct.
The nurse is assessing a client with a suspected acute pancreatitis. Which of the following laboratory findings is most indicative of this condition?
- A. Elevated amylase and lipase.
- B. Decreased white blood cell count.
- C. Elevated hemoglobin.
- D. Decreased blood glucose.
Correct Answer: A
Rationale: Elevated amylase and lipase are hallmark laboratory findings in acute pancreatitis due to pancreatic enzyme release.