Nokea
A 7-year-old daughter weighs 50.25 lb (22.85 kg) and is 48 inches (121.7 cm) tall. The nurse notes that she has gained 2.5 pounds and has grown 3 inches in the past year.
Which of the following responses by the nurse is BEST?
- A. Your daughter's height and weight are within normal limits.'
- B. Your daughter's height is normal, but she needs to gain some weight.'
- C. Your daughter's height is normal, but she needs to lose some weight.'
- D. Your daughter's weight is normal, but she is shorter than normal.'
Correct Answer: A
Rationale: Strategy: 'BEST' indicates that you will have to discriminate between answers. The topic of the question is unstated. Read answer choice to obtain clues. (1) correct-between ages 6-12 grows about 2 in (5 cm)/year and gains 4.5-6.5 lb (2-3 kg)/year, at age 7 average 39-66.5 lb (17.7-30 kg) and 44-51 in (111.8-129.7 cm) (2) weight is within normal limits (3) weight is within normal limits (4) height is within normal limits
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A 63-year-old woman is taking digitalis, baby aspirin, potassium (K-Dur), and furosemide (Lasix) daily. She complains of multiple symptoms, which include muscle cramps and facial tics. Physical exam reveals positive Chvostek's and Trousseau's signs, hypotension, and confusion. The nurse suspects she has hypomagnesemia. What else should the nurse expect?
- A. Laboratory tests to reveal high serum calcium and potassium levels
- B. Laboratory tests to reveal low serum calcium and potassium levels
- C. Altered acid-base balance, which requires administration of NaHCO3 intravenously in addition to treatment for hypomagnesemia
- D. An order for an ECG to monitor brain function
Correct Answer: B
Rationale: Hypomagnesemia often accompanies low calcium and potassium, as seen with furosemide use, explaining symptoms like cramps and tetany.
Which of the following snacks would be suitable for a child with gluten-induced enteropathy?
- A. A soft oatmeal cookie
- B. Buttered popcorn
- C. A peanut butter and jelly sandwich
- D. Cheese pizza
Correct Answer: B
Rationale: Buttered popcorn is gluten-free, making it suitable for a child with celiac disease (gluten-induced enteropathy). The other options contain gluten.
The nurse is caring for a client who is postoperative day 1 after a lumbar laminectomy. Which of the following actions should the nurse prioritize?
- A. Encourage log-rolling when repositioning
- B. Administer pain medication as needed
- C. Keep the head of the bed elevated 45 degrees
- D. Monitor the surgical drain for output
Correct Answer: A
Rationale: Log-rolling maintains spinal alignment, preventing complications post-laminectomy. Options B, C, and D are secondary: pain management is routine, 45-degree elevation is excessive, and drain monitoring is less urgent.
A client with symptoms supportive of a diagnosis of Guillain-Barré syndrome.
The nurse knows that which of the following symptoms would be supportive of a diagnosis of Guillain-Barré syndrome?
- A. Hemiplegia, hypertension, tachycardia.
- B. Respiratory failure, flaccid paralysis, urinary retention.
- C. Peripheral edema, hypertension, pulmonary congestion.
- D. Diminished reflexes, pain, paresthesia.
Correct Answer: B
Rationale: Strategy: All parts of the answer choice must be correct in order for the answer to be correct. (1) relates to a CVA (2) correct-classic symptoms include respiratory failure and flaccidity due to paralysis of the muscles and urinary retention due to loss of sensation (3) relates to pulmonary edema (4) relates to peripheral nerve problems
The nurse is assessing a dark-skinned client with anemia. Which part of the body would the nurse assess for pallor?
- A. Nail beds
- B. Hard palate
- C. Sclera
- D. Buccal mucosa
Correct Answer: D
Rationale: The buccal mucosa is reliable for assessing pallor in dark-skinned clients, as skin pigmentation may mask changes elsewhere.