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Questions 158

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Question 1 of 5

Which behaviors are expected to be observed in the 18-month old?

Correct Answer: B, C, E

Rationale: At 18 months, children remove clothes (
B), point to body parts (
C), and kick balls (E). Vocabulary is ~20-50 words (
A), and questioning (
D) emerges later (~2-3 years).

Question 2 of 5

Which actions should be utilized prior to performing a tub bath on the 80 year-old client?

Question Image

Correct Answer: B, D

Rationale: For an 80-year-old client, safety and comfort are priorities during a tub bath. A rubber mat (
B) prevents slipping, crucial for elderly clients with reduced mobility. Checking water temperature with a bath thermometer (
D) ensures the water is safe (typically 38-40°C, as 46°C is too hot). Filling the tub half full at 46°C (
A) risks burns, and maintaining water flow pressure (
C) is unnecessary and unsafe. Washing the back (E) and performing a massage (F) occur during or after the bath, not prior.

Question 3 of 5

The nurse is teaching circumcision care to the mother of a newborn. Which statement indicates that the mother needs further teaching?

Correct Answer: C

Rationale: Using a heat lamp is incorrect and could cause burns or delay healing. Petroleum gauze, cleaning, and monitoring for infection are appropriate circumcision care practices.

Question 4 of 5

When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is:

Correct Answer: A

Rationale:
Stephens-Johnson syndrome is a toxic effect of phenytoin. Folate deficiency is a side effect of phenytoin, but not a toxic effect. Leukopenic aplastic anemia is a toxic effect of carbamazepine (Tegretol). Granulocytosis and nephrosis are toxic effects of trimethadione (Tridione).

Question 5 of 5

An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising pulse rate and lowering blood pressure, the nurse would suspect that the client:

Correct Answer: B

Rationale: Rising pulse rate and lowering blood pressure are indicative of hypovolemia, which is consistent with an internal injury causing blood loss.

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