Nokea
A client with pneumonia.
Which of the following nursing observations would indicate a therapeutic response to the treatment?
- A. Oral temperature of 101°F (38.3°C), increased chest pain with nonproductive cough.
- B. Cough, productive of thick green sputum, client reports feeling tired.
- C. Respirations at 20 with no complaints of dyspnea, moderate amount of thin white sputum.
- D. White cell count of 10,000 mm³, urine output at 40 cc per hour, decreasing amount of sputum.
Correct Answer: C
Rationale: Strategy: Determine which answer choice indicates an improved respiratory status. (1) validates the continued presence of the infection (2) validates the continued presence of the infection (3) correct-sputum characteristics indicate a decrease in the pneumonia; is supported by respiratory status (4) does not substantiate the status of the infection
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Which play activity is most appropriate for a 15-month-old with a cyanotic heart defect?
- A. Push-and-pull toy
- B. Mobile
- C. Shape sorter
- D. Pounding board
Correct Answer: B
Rationale: A mobile is a passive activity suitable for a 15-month-old with a cyanotic heart defect, as it avoids exertion, so B is correct. Push-and-pull toys , shape sorters , and pounding boards require more physical effort.
A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure?
- A. Playing with toys in a back yard flower garden
- B. Eating small amounts of grass while playing 'farm'
- C. Playing with cars on the pavement near burning leaves
- D. Throwing a ball to a neighborhood child who has poison ivy
Correct Answer: C
Rationale: Playing with cars on the pavement near burning leaves. Smoke from burning leaves or stems of the poison ivy plant can produce a reaction. Direct contact with the toxic oil, urushiol, is the most common cause for this dermatitis.
The nurse is performing hypertension screening at the local grocery store. It would be MOST important for the nurse to complete which of the following tasks?
- A. Use a blood pressure cuff that overlaps the arm at least four inches.
- B. Support the client's arm above the level of the heart.
- C. Take two readings at least five minutes apart.
- D. Take the blood pressure after the client has exercised for 10 minutes.
Correct Answer: C
Rationale: Two readings five minutes apart ensure accuracy in hypertension screening. Options A, B, and D are incorrect techniques.
Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies?
- A. Risk for injury
- B. Risk for knowledge deficit
- C. Altered thought process
- D. Disturbance in self-esteem
Correct Answer: A
Rationale: Risk for injury. Impaired judgment from substance abuse significantly increases the risk of accidents and injuries.
Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence?
- A. Steadily increasing vital signs.
- B. Mild tremors and irritability.
- C. Decreased respirations and disorientation.
- D. Stomach distress and inability to sleep.
Correct Answer: A
Rationale: Steadily increasing vital signs (e.g., heart rate, blood pressure) indicate progression toward delirium tremens, a life-threatening complication of alcohol withdrawal, necessitating additional sedation. Mild tremors, decreased respirations, or gastroinTest inal symptoms are expected or contraindicate more sedation.