The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. Which of the following would be an appropriate response?

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Question 1 of 9

The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. Which of the following would be an appropriate response?

Correct Answer: D

Rationale: The correct response is D because it encourages the mother to provide specific information about the toddler's behavior indicating pain. This helps the nurse assess the severity and nature of the earache accurately. Options A and C are dismissive and may overlook a potential health issue. Option B suggests immediate action without gathering information first, which may not be necessary.

Question 2 of 9

The papule on the nose of a 52-year-old woman has rounded, pearly borders and a central red ulcer. She tells the nurse that it has been present for several months and is slowly growing larger. Which of the following conditions does the nurse suspect?

Correct Answer: B

Rationale: The correct answer is B: Basal cell carcinoma. The clinical presentation of a papule with rounded, pearly borders, central red ulcer, slow growth, and location on the nose is highly indicative of basal cell carcinoma. Basal cell carcinoma commonly presents with these characteristics and is the most common type of skin cancer. It is locally invasive but rarely metastasizes. A: Acne is a common skin condition characterized by comedones, papules, and pustules, not typically presenting with the described features. C: Malignant melanoma usually presents as an asymmetric, irregularly bordered, multicolored lesion with rapid growth and potential for metastasis. D: Squamous cell carcinoma typically presents as a scaly, crusted lesion with potential for metastasis, not showing the described features.

Question 3 of 9

The nurse suspects that a patient has hyperthyroidism, and laboratory data also indicate that the patient's T and T hormone levels are elevated. Which of the following would the nurse most likely find on 4 3 examination?

Correct Answer: A

Rationale: Step-by-step rationale for why choice A (Tachycardia) is correct: 1. Hyperthyroidism leads to increased production of thyroid hormones. 2. Thyroid hormones can increase metabolic rate and heart rate. 3. Tachycardia is a common symptom of hyperthyroidism due to increased metabolic demand. 4. Therefore, the nurse would most likely find tachycardia on examination in a patient with hyperthyroidism. Summary of why other choices are incorrect: B: Constipation - Constipation is more commonly associated with hypothyroidism, not hyperthyroidism. C: Rapid dyspnea - Dyspnea (shortness of breath) is not a typical symptom of hyperthyroidism. D: Atrophied, nodular thyroid - Hyperthyroidism often presents with an enlarged, not atrophied, thyroid gland due to overactivity. Nodules may be present in conditions like thyroid cancer, but not specific to hyper

Question 4 of 9

What is the nurse's priority when caring for a client experiencing a severe allergic reaction?

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. The priority in a severe allergic reaction is to quickly address the life-threatening symptoms like anaphylaxis. Epinephrine is the first-line treatment as it helps reverse the effects of the allergic reaction by opening airways and increasing blood pressure. Administering antihistamines (choices B and D) can help relieve itching and hives but are not as effective in treating severe symptoms. Monitoring respiratory status (choice C) is important but administering epinephrine takes precedence to stabilize the client's condition.

Question 5 of 9

A nurse is caring for a 70-year-old patient with a history of congestive heart failure. The nurse should monitor the patient for which of the following?

Correct Answer: A

Rationale: The correct answer is A: Orthostatic hypotension. In a patient with congestive heart failure, there is impaired cardiac function leading to decreased cardiac output. This can result in orthostatic hypotension, where blood pressure drops upon standing. Monitoring for orthostatic hypotension is important to prevent falls and other complications. B: Hyperkalemia is not typically associated with congestive heart failure. C: Hypoglycemia may occur in patients with diabetes, but it is not a common complication of congestive heart failure. D: Severe dehydration is not directly related to congestive heart failure unless the patient has concurrent issues such as diarrhea or excessive diuresis.

Question 6 of 9

Which medication should be given to treat anemia in clients with renal failure?

Correct Answer: A

Rationale: Correct Answer: A (Iron, folic acid, and B12) Rationale: 1. Iron: Renal failure patients often have anemia due to decreased erythropoietin production. 2. Folic acid and B12: Important for red blood cell production and maturation. 3. Corrects underlying causes of anemia in renal failure patients. Summary: B: Increasing protein doesn't directly address anemia in renal failure. C: Vitamin D and calcium are not primary treatments for anemia in renal failure. D: Calcium and folic acid alone do not address the specific deficiencies seen in renal failure anemia.

Question 7 of 9

The nurse is conducting an eye clinic at the day care centre. When examining a 2-year-old child, if"lazy eye" is suspected, the nurse would:

Correct Answer: D

Rationale: The correct answer is D because testing for strabismus by performing the corneal light reflex test is crucial in diagnosing "lazy eye" or amblyopia in children. Strabismus is a condition where the eyes are misaligned, leading to poor vision in one eye. By performing the corneal light reflex test, the nurse can assess if the child's eyes are aligned or if there is deviation, which could indicate lazy eye. Options A, B, and C are incorrect as they do not specifically address the assessment of strabismus, which is the key indicator for lazy eye in this scenario.

Question 8 of 9

The nurse is caring for a client moving toward illness and premature death. How would the nurse know this?

Correct Answer: B

Rationale: The correct answer is B. When a client is moving towards illness and premature death, signs and symptoms typically start to manifest. These can include physical changes, abnormal lab results, or new onset of health issues. This serves as a direct indication of the client's deteriorating health status. Choices A, C, and D are incorrect because stopping wellness-promoting activities (A) could simply be due to lack of motivation, starting to exercise (C) may not necessarily indicate illness progression, and verbalizing anxiety over medication costs (D) is not a direct indicator of impending illness and premature death.

Question 9 of 9

What is the most appropriate nursing diagnosis for a client with advanced Parkinson's disease and gait issues?

Correct Answer: A

Rationale: The most appropriate nursing diagnosis for a client with advanced Parkinson's disease and gait issues is "A: Impaired Physical Mobility." This diagnosis accurately reflects the client's limited ability to move due to the disease's impact on coordination and muscle control. Impaired Physical Mobility addresses the specific issue of gait problems commonly seen in Parkinson's patients. Choice B, "Impaired Role Performance," does not directly address the physical limitations caused by the disease. Choice C, "Ineffective Role Performance," focuses more on the client's inability to fulfill societal roles rather than the physical aspect of gait issues. Choice D, "Powerlessness," does not capture the primary concern of impaired movement and mobility in this scenario.

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