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Questions 158

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Question 1 of 5

The nurse is preparing to administer an injection to a six-month-old when she notices a white dot in the infant's right pupil. The nurse should:

Correct Answer: A

Rationale: A white dot in the pupil (leukocoria) may indicate retinoblastoma or other serious conditions, requiring immediate reporting to the physician for evaluation.

Question 2 of 5

A behavior-modification program has been started for an adolescent with oppositional defiant disorder. Which statement describes the use of behavior modification?

Correct Answer: C

Rationale: Behavior modification for oppositional defiant disorder often uses a token economy system, where positive behaviors are reinforced with rewards to encourage compliance.

Question 3 of 5

A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first nursing actions would be essential in this situation?

Correct Answer: B

Rationale: Nausea, tachycardia, and irritability are all symptoms of theophylline toxicity. The physician should be notified immediately so that a serum theophylline level can be ordered.

Question 4 of 5

A 16-year-old female client is admitted to the hospital because she collapsed at home while exercising with videotaped workout instructions. Her mother reports that she has been obsessed with losing weight and staying slim since cheerleader try-outs 6 months ago, when she lost out to two of her best friends. The client is 5'4'' and weighs 92 lb, which represents a weight loss of 28 lb over the last 4 months. The most important initial intervention on admission is to:

Correct Answer: C

Rationale: Vital signs are a high priority when working with self-destructive clients.

Question 5 of 5

The client has an order for Garamycin (gentamicin) to be administered. Which lab test should be done before beginning the medication?

Correct Answer: B

Rationale: Gentamicin, an aminoglycoside, is nephrotoxic. Serum creatinine is monitored before administration to assess baseline kidney function, as impaired renal function increases toxicity risk. Hematocrit, white cell count, and BUN are less specific for gentamicin.

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