Nokea
You measure your 2 year old client's vital signs as: • Respiratory rate: 32 breaths per minute • Pulse: 110 beats per minute • Blood pressure: 55/82. The mother asks you if these vital signs are normal. You should respond to this mother's question by stating:
- A. The respiratory rate is a little too fast but the other vital signs are normal.'
- B. The pulse rate is a little too fast but the other vital signs are normal.'
- C. The blood pressure is a little low but the other vital signs are normal.'
- D. All of these vital signs are normal for a child that is 2 years of age.'
Correct Answer: C
Rationale: For a 2-year-old, normal ranges are approximately: respiratory rate 20-30 breaths/min, pulse 80-130 beats/min, blood pressure ~90/55 mmHg. The blood pressure (55/82) is low (systolic is below normal), while the respiratory rate and pulse are within or slightly above normal ranges.
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A client who has glaucoma has been prescribed timolol (Timoptic) eyedrops. Which of the following instructions should the nurse give the client about the administration of the eyedrops?
- A. Instill the eyedrops whenever the eyes feel irritated
- B. The medication may cause some transient eye discomfort
- C. Keep the medication refrigerated between doses
- D. The need to use the eyedrops will be reevaluated after 1 month
Correct Answer: B
Rationale: Timolol eyedrops may cause transient eye discomfort, such as stinging or burning, which is a common side effect. Instilling drops only when eyes are irritated is incorrect, as timolol requires regular dosing. Refrigeration is not necessary, and reevaluation timing depends on the physician's plan, not a fixed month.
A client with a history of schizophrenia is prescribed aripiprazole (Abilify). The nurse should monitor the client for which of the following adverse effects?
- A. Akathisia.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: A
Rationale: Aripiprazole can cause akathisia, a movement disorder, requiring monitoring.
A client with a spinal cord injury is at risk for autonomic dysreflexia. Which symptom should the nurse monitor for?
- A. Bradycardia.
- B. Hypotension.
- C. Severe headache.
- D. Increased urine output.
Correct Answer: C
Rationale: Severe headache is a key sign of autonomic dysreflexia, often triggered by bladder or bowel issues.
You have decided to use the Dimensions Model of Health model to assess, monitor and evaluate the health status of the community. Which of these dimensions is NOT an element of this Dimensions Model of Health model?
- A. The Biophysical Dimension
- B. The Psychological and Emotional Dimension
- C. The Spiritual Dimension
- D. The Health Systems Dimension
Correct Answer: D
Rationale: The Dimensions Model of Health typically includes biophysical, psychological, social, and spiritual dimensions. The Health Systems Dimension is not a standard component of this model.
The nurse talks to students at a high school about sexually transmitted infections (STIs). Which effective methods of preventing STIs does the nurse include in the discussion? Select all that apply.
- A. Some birth control pills prevent STIs.
- B. STIs do not transmit through oral sex.
- C. Diaphragms are a barrier against STIs.
- D. Abstinence prevents transmission of STIs.
- E. Proper condom use provides STI protection.
- F. Multiple sex partners increase the risk of STIs.
Correct Answer: D,E,F
Rationale: Effective measures to avoid STIs include abstinence, using condoms properly, and avoiding multiple partners, and the nurse should provide this factual information to the high school students. The nurse also includes information about ineffective methods of preventing STIs, including birth control pills, oral sex, and diaphragms.