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Questions 158

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Extract:


Question 1 of 5

Which one of the following situations represents a maturational crisis for the family?

Correct Answer: A

Rationale: A maturational crisis involves normal developmental transitions, such as a child entering nursery school, which can stress family dynamics.

Question 2 of 5

A client with a history of a thyroidectomy is being discharged. The nurse should teach the client to:

Correct Answer: D

Rationale: Muscle twitching post-thyroidectomy may indicate hypocalcemia from parathyroid damage, requiring immediate reporting. Hyperthyroidism, calcium foods, and bedtime dosing are not primary concerns.

Question 3 of 5

A five-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?

Correct Answer: D

Rationale: Constant swallowing post-tonsillectomy suggests bleeding, as the child may be swallowing blood from the surgical site, a serious complication requiring immediate attention. Decreased appetite and low-grade fever are expected, and chest congestion is unrelated.

Question 4 of 5

Which task should be delegated to the licensed practical nurse?

Question Image

Correct Answer: A, B, D, E

Rationale: LPNs can administer subcutaneous heparin (
A), feed via PEG tube (
B), monitor chest tubes (
D), and perform tracheostomy care (E). Removing a PICC line (
C) requires RN-level expertise due to potential complications.

Question 5 of 5

A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:

Correct Answer: D

Rationale: Muscle rigidity and fever suggest neuroleptic malignant syndrome (NMS), a life-threatening reaction to olanzapine. Immediate transfer to a medical unit for urgent treatment is critical.

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