Nokea
Which of the following statements describes Piaget's stage of concrete operations?
- A. Reflex activity proceeds to imitative behavior.
- B. The ability to see another's point of view increases.
- C. Thought processes become more logical and coherent.
- D. The ability to think abstractly leads to logical conclusion.
Correct Answer: C
Rationale: Piaget's concrete operations stage (ages 7-11) involves logical, coherent thinking about concrete events, not abstract concepts. Perspective-taking improves but is secondary to logical thought.
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A client has renal failure. Today's lab values indicate he has an elevated serum potassium. What additional priority information does the nurse need to obtain?
- A. Evaluation of his level of consciousness
- B. Evaluation of an electrocardiogram
- C. Measurement of his urine output for the past 8 hours
- D. Serum potassium lab values for the last several days
Correct Answer: B
Rationale: The level of consciousness is not affected by elevated potassium levels. An electrocardiogram (EKG) can tell the nurse whether this client is experiencing any cardiac dysfunction or arrhythmias related to the elevated potassium level. Measurement of the urine output is not a priority nursing action at this time. The client's serum potassium values for the past several days may provide information about his renal function, but they are not a priority at this time.
While the nurse is taking a male client's blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:
- A. Politely tells the client, 'Keep your hands off'
- B. Ignores the remarks and hopes he will not try it again
- C. Confronts the remarks but attempts not to reject the client
- D. Leaves the room in order to compose herself
Correct Answer: C
Rationale: By confronting the remarks, she can recognize that his feelings of attraction may be normal but are not appropriate within the context of their nurse-client relationship.
Before administering intravenous chemotherapy to the patient being treated, the nurse should:
- A. Administer a bolus of IV fluid
- B. Administer pain medication
- C. Administer an antiemetic
- D. Allow the patient a chance to eat
Correct Answer: C
Rationale: Chemotherapy often causes nausea and vomiting, so administering an antiemetic prophylactically is standard to improve patient comfort. Fluid boluses, pain medication, or eating are not routine pre-chemotherapy steps unless specified.
The client is admitted to the ER with multiple rib fractures on the right. The nurse's assessment reveals that an area over the right clavicle is puffy and that there is a "crackling" noise with palpation. The nurse should further assess the client for which of the following problems?
- A. Flail chest
- B. Subcutaneous emphysema
- C. Infiltrated subclavian IV
- D. Pneumothorax
Correct Answer: B
Rationale: Puffy skin and crackling (crepitus) over the clavicle suggest subcutaneous emphysema, where air escapes into tissues, often with rib fractures. Flail chest (A) involves paradoxical chest movement, infiltrated IV (C) is unrelated, and pneumothorax (D) causes absent breath sounds.
The mother of a child taking phenytoin will need to plan appropriate mouth care and gingival stimulation. When tooth-brushing is contraindicated, the next most effective cleansing and gingival stimulation technique would be:
- A. Using a water pik
- B. Rinsing with water
- C. Rinsing with hydrogen peroxide
- D. Rinsing with baking soda
Correct Answer: A
Rationale: This technique provides effective rinsing and gingival stimulation. This technique does not provide gingival stimulation. This technique provides effective rinsing but not gingival stimulation. Using peroxide is not pleasant for the child. This technique provides effective rinsing but not gingival stimulation.