The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teaching if the client stated

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Question 1 of 5

The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teaching if the client stated

Correct Answer: C

Rationale: Trimming corns/calluses risks injury in arterial insufficiency; professional care is needed.

Question 2 of 5

A 6 month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents to

Correct Answer: C

Rationale: Monitoring for swelling ensures circulation isn't compromised by the cast.

Question 3 of 5

The nurse is assessing a newborn the day after birth. A high pitched cry, irritability and lack of interest in feeding are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing care?

Correct Answer: A

Rationale: Reducing stimuli addresses irritability, possibly due to withdrawal or stress.

Question 4 of 5

A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78 BPM; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity?

Correct Answer: A

Rationale: Bradycardia (pulse 78 BPM, low for an infant) is a classic sign of digoxin toxicity.

Question 5 of 5

The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be

Correct Answer: A

Rationale: Healthy ego defenses reduce fear and maintain self-esteem adaptively.

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