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Questions 158

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Question 1 of 5

The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:

Correct Answer: B

Rationale: Apraxia is the inability to perform purposeful movements or use objects correctly such as using a toothbrush to brush hair. Agnosia involves sensory misrecognition anomia is difficulty naming objects and aphasia affects language.

Question 2 of 5

A 2-year-old child will undergo a cardiac catheterization tomorrow to evaluate his ventricular septal defect. Based on his developmental stage, the nurse:

Correct Answer: B

Rationale: A toddler is not capable of conceptualizing about the inside of his body and is concerned about body intactness; therefore, diagrams would not be useful. Also, the previous evening is too far from the procedure for the toddler to remember the instructions. A simple explanation the morning of the procedure is the best developmental strategy to use, because it focuses on the toddler's need for parental support, body intactness, and short attention span. A relationship between the nurse and the child needs to develop. Also, misinformation may be given to the child if the parents explain the procedure to the child. The parents are the child's support system and need to be there to strengthen the child.

Question 3 of 5

The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should:

Correct Answer: C

Rationale: The nasal discharge could be due to a cold. It is necessary to gather additional assessment data to identify a possible cerebrospinal fluid leak. If the discharge is cerebrospinal fluid, it would not be safe to encourage the girl to blow her nose. Cerebrospinal fluid is positive for sugar; mucus is not. Turning her to her side will have no effect on her 'runny nose.' It is necessary to gather further assessment data.

Question 4 of 5

A nurse is assisting the physician with chest tube removal. Which client instruction is appropriate during removal of the tube?

Correct Answer: A

Rationale: Taking a deep breath or humming (Valsalva maneuver) during chest tube removal increases intrathoracic pressure, preventing air entry. Holding breath for two minutes (
B) is excessive, exhaling (
C) risks pneumothorax, and deep breathing (
D) is unsafe.

Question 5 of 5

The nurse is caring for a client with a diagnosis of preeclampsia. Which laboratory test is most likely to be ordered?

Correct Answer: D

Rationale: Preeclampsia requires monitoring platelet count (for thrombocytopenia) liver enzymes (for HELLP syndrome) and urinalysis (for proteinuria). All tests are essential to assess disease severity and complications.

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