Nokea
Which term describes the play activity of the preschool aged child?
- A. Cooperative
- B. Associative
- C. Parallel
- D. Solitary
Correct Answer: B
Rationale: Preschool-aged children (3–5 years) typically engage in associative play, where they play together with shared activities but without formal rules or organization. Cooperative play develops later, parallel play is common in toddlers, and solitary play is seen in younger children.
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The nurse is caring for a client with a history of asthma who is receiving Albuterol (Proventil). The nurse should monitor the client for:
- A. Tachycardia
- B. Hypotension
- C. Hypokalemia
- D. Hyperglycemia
Correct Answer: A
Rationale: Albuterol, a beta-agonist, commonly causes tachycardia as a side effect due to sympathetic stimulation. Hypotension, hypokalemia, and hyperglycemia are less frequent.
The client is admitted with a diagnosis of preeclampsia. The nurse should monitor for which complication?
- A. Seizures
- B. Premature rupture of membranes
- C. Fetal macrosomia
- D. Maternal hypoglycemia
Correct Answer: A
Rationale: Preeclampsia can progress to eclampsia characterized by seizures a life-threatening complication. Premature rupture of membranes macrosomia and hypoglycemia are not directly related to preeclampsia.
The nurse is caring for a client with a closed head injury. Which intervention is most important to prevent increased intracranial pressure (ICP)?
- A. Keep the head of the bed elevated 30–45 degrees.
- B. Administer acetaminophen for headache.
- C. Provide frequent oral care.
- D. Encourage deep breathing exercises.
Correct Answer: A
Rationale: Elevating the head of the bed 30–45 degrees promotes venous drainage, reducing ICP. Acetaminophen (B), oral care (C), and breathing exercises (D) are supportive but less critical for ICP control.
A client with a history of testicular cancer is admitted with complaints of back pain. The nurse should give priority to:
- A. Monitoring for metastasis
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Back pain in testicular cancer may indicate metastasis to retroperitoneal lymph nodes, so monitoring for metastasis is the priority.
A 71-year-old client fell and injured her left leg while cooking in the kitchen. Her husband calls the ambulance, and she is taken to the emergency department at a local hospital. X-ray reports confirm that she has an intertrochanteric fracture of the left femur. Her left leg will require skeletal traction initially and then surgery. The nurse knows that this type of traction will be used:
- A. By inserting pins to provide steady pull on the bone
- B. To suspend the leg in a sling without pull on the extremity
- C. Intermittently to place a pull over the pelvis and lower spine
- D. With weights at both ends of the bed to maintain pull on the upper extremity
Correct Answer: A
Rationale: Skeletal traction is the application of traction directly to bone with the use of pins and wires or tongs for the purpose of providing a strong, steady, continuous longitudinal pull on the bone. It is indicated for preoperative immobilization and positioning of hip and femur fractures. A type of skeletal traction (balanced suspension with a Thomas splint and Pearson attachment) uses a sling to support the extremity, but it also uses weights to provide a strong, steady continuous pull on the extremity. A sling is used instead of pins. Pelvic traction provides an intermittent pull over the pelvis and bone, whereas skeletal traction is continuous. Pelvic traction does not use pins. Skeletal traction uses weights at the end of the bed to provide a continuous pull on long bones. Weights are not applied to both ends of the bed.