Nokea
Which of the following statements describes what the nurse must know in order to provide anticipatory guidance to parents of a toddler about readiness for toilet training?
- A. The child learns voluntary sphincter control through repetition
- B. Myelination of the spinal cord is completed by this age
- C. Neuronal impulses are interrupted by the ganglia
- D. The toddler can understand cause and effect
Correct Answer: B
Rationale: Myelination of the spinal cord is completed by this age, enabling voluntary sphincter control between 18 to 24 months.
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The doctor has prescribed imipramine (Tofranil) for an elderly client with endogenous depression. The nurse should give priority to assessing the client's:
- A. Fluid intake
- B. Cardiac status
- C. Respiratory effort
- D. Urinary output
Correct Answer: B
Rationale: Imipramine, a tricyclic antidepressant, can cause cardiac arrhythmias, especially in the elderly, making cardiac status assessment a priority.
A client is in suspected shock state from major trauma. Which of the following parameters indicate the adequacy of peripheral perfusion? Select all that apply.
- A. Apical pulse
- B. Capillary refill time
- C. Lung sounds
- D. Pupillary response
- E. Skin color and temperature
Correct Answer: B,E
Rationale: Capillary refill time and skin color/temperature directly assess peripheral perfusion in shock. Apical pulse , lung sounds , and pupillary response evaluate other aspects.
At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform?
- A. Say 2 words
- B. Pull up to stand
- C. Sit without support
- D. Drink from a cup
Correct Answer: C
Rationale: Sit without support. This is a typical developmental milestone for an 8-month-old.
The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the post-operative period?
- A. Estrogen replacement therapy
- B. 10% less than ideal body weight
- C. Hypersensitivity to heparin
- D. History of hepatitis
Correct Answer: A
Rationale: Estrogen increases the hypercoagulability of the blood and increases the risk for development of thrombophlebitis.
When counseling a 6 year-old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder?
- A. It has no clear etiology
- B. Enuresis may be associated with sleep phobia
- C. It has a definite genetic link
- D. Enuresis is a sign of willful misbehavior
Correct Answer: A
Rationale: It has no clear etiology. Enuresis has multiple contributing factors, but no single definitive cause has been established.