Nokea
Which toys are suited to the developmental skills of the 2-3 year old?
- A. Soap bubbles
- B. Skates
- C. Riding toys
- D. Bicycle
- E. Talking toys
Correct Answer: A, C, E
Rationale: For 2-3-year-olds, soap bubbles (A), riding toys (C), and talking toys (E) match gross motor and imaginative play skills. Skates (B) and bicycles (D) require advanced coordination.
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The nurse is caring for a client with a history of a hiatal hernia who is receiving Propulsid (cisapride). The nurse should monitor the client for:
- A. Arrhythmias
- B. Hypotension
- C. Constipation
- D. Weight gain
Correct Answer: A
Rationale: Cisapride can prolong the QT interval, risking arrhythmias, requiring cardiac monitoring. Hypotension, constipation, and weight gain are not primary side effects.
The nurse is caring for a client with a history of a pneumothorax who is being prepared for discharge. The nurse should teach the client to:
- A. Avoid air travel
- B. Sleep on the affected side
- C. Resume heavy lifting
- D. Restrict fluid intake
Correct Answer: A
Rationale: Air travel can cause pressure changes that risk pneumothorax recurrence. Sleeping position, lifting, and fluids are secondary, with lifting typically restricted.
A client with a history of liver cirrhosis is admitted with complaints of ascites. The nurse should give priority to:
- A. Monitoring for infection
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering diuretics
Correct Answer: A
Rationale: Ascites increases infection risk (e.g., spontaneous bacterial peritonitis) in cirrhosis, so monitoring for infection is the priority.
Which finding in the patient's history contraindicates the use of Imitrex (sumatriptan) for the prevention of migraine headaches?
- A. Diabetes
- B. Angina
- C. Renal calculi
- D. Peptic ulcer disease
Correct Answer: B
Rationale: Sumatriptan (Imitrex) is a vasoconstrictor contraindicated in patients with angina due to the risk of coronary artery vasoconstriction and ischemia. Diabetes renal calculi and peptic ulcer disease are not contraindications for sumatriptan.
A client with a history of atrial fibrillation is admitted with complaints of palpitations. The nurse should expect the client to have:
- A. Irregular pulse
- B. Bradycardia
- C. Hypertension
- D. Chest pain
Correct Answer: A
Rationale: Atrial fibrillation causes an irregular pulse due to disorganized atrial contractions, a hallmark of the condition.