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Questions 164

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Extract:


Question 1 of 5

The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up?

Correct Answer: D

Rationale: A 30 month-old only drinking from a sippy cup. A 30 month-old should be able to drink from a cup without a cover.

Question 2 of 5

A client is admitted to the burn unit with an electrical burn. Which of the following areas probably sustained the greatest degree of injury?

Correct Answer: B

Rationale: Electrical burns cause deep tissue damage, with intrathoracic organs (heart, lungs) at greatest risk due to the current's path through the body.

Question 3 of 5

An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse?

Correct Answer: B

Rationale: Asking about recent food intake helps identify unintentional gluten exposure, common in new celiac diagnoses. Assuming 6-8 weeks, immediate referral, or blaming non-compliance may overlook dietary errors or other causes.

Extract:

Laboratory reference ranges
Potassium3.5-5.0 mEq/L(3.5-5.0 mmol/L)
INRNormal: 0.8-1.1Therapeutic: 1.5-4.0


Question 4 of 5

The nurse recognizes which of the following factors as possibly contributing to a sentinel event?

Correct Answer: A

Rationale: Administering warfarin with an INR of 6.0 (therapeutic range 2.0-3.0) risks severe bleeding, a sentinel event. Flumazenil is appropriate for lorazepam overdose, nitroprusside for hypertensive crisis, and insulin/dextrose for hyperkalemia are correct interventions.

Extract:


Question 5 of 5

The health care provider prescribes a multivitamin regimen that includes thiamine for a client with a history of chronic alcohol abuse. The nurse is aware that thiamine is given to this client population for which purpose?

Correct Answer: C

Rationale: Thiamine prevents Wernicke encephalopathy, a neurological disorder from thiamine deficiency common in chronic alcoholism. It does not lower alcohol levels, prevent tremors, or treat seizures directly.

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