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NEW QUESTION 54
The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take?

A. Move furniture out of the way and place a blanket under his head.B. Place a tongue blade in the child's mouth.C. Go to the nurses station and call the physician.D. Restrain the child so he will not injure himself.

Answer: A

Explanation:
Explanation
(A) The nurse should not put anything in the child's mouth during a seizure; this action could obstruct the airway. (B) Restraining the child's movements could cause constrictive injury. (C) Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. (D) The nurse should provide safety for the child by moving objects and protecting the head.

 

NEW QUESTION 55
Four days after admission for cirrhosis of the liver, the nurse observes the following when assessing a male client: increased irritability, asterixis, and changes in his speech pattern. Which of the following foods would be appropriate for his bedtime snack?

A. A ham and cheese sandwichB. Fresh fruitC. A milkshakeD. Saltine crackers and peanut butter

Answer: B

Explanation:
(A) High levels of ammonia, a by-product of protein metabolism, can precipitate metabolic encephalopathy. These clients need a diet high in carbohydrates and bulk. (B) Metabolic encephalopathy of the brain associated with liver failure is precipitated by elevated ammonia levels. Ammonia is a by-product of protein metabolism. (C, D) Metabolic encephalopathy in liver failure is precipitated by elevated ammonia levels. Ammonia is a by-product of protein metabolism.

 

NEW QUESTION 56
A 4-year-old child has Down syndrome. The community health nurse has coordinated a special preschool program. The nurse's primary goal is to:

A. Prepare child to enter mainstream educationB. Provide a demanding and challenging educational programC. Facilitate optimal developmentD. Provide respite care for the mother

Answer: C

Explanation:
Explanation/Reference:
Explanation:
(A) Respite care for the family may be needed, but it is not the primary goal of a preschool program. (B) Facilitation of optimal growth and development is essential for every child. (C) A demanding and challenging educational program may predispose the child to failure. Children with retardation should begin with simple and challenging educational programs. (D) Mental retardation associated with Down syndrome may not permit mainstream education. A preschoolprogram's primary goal is not preparation for mainstream education but continuation of optimal development.

 

NEW QUESTION 57
A 28-year-old client comes to the clinic for her first prenatal examination. In relating her obstetrical history, she tells the nurse that she has been pregnant twice before. She had a "miscarriage" with the first pregnancy after
6 weeks. With the second pregnancy, she delivered twin girls at 31 weeks' gestation. One of the twins was stillborn and the other twin died at 4 days of age. Using a five-digit system, the nurse records her as being:

A. 3-0-1-1-0B. 2-1-1-0-0C. 2-2-2-1-2D. 2-0-2-1-0

Answer: A

Explanation:
Section: Questions Set E
Explanation:
(A) The first digit represents the total number of pregnancies. This client has been pregnant 3 times including this pregnancy. The twin pregnancy counts as only one pregnancy, and because she delivered prior to 37 weeks' gestation, the third digit is recorded as 1. (B) The first digit represents the total number of pregnancies.
This client has been pregnant 3 times including this pregnancy. The second digit represents the total number of full-term deliveries; she has lost two pregnancies before 37 weeks' gestation. At present, she has no living children, so the fifth digit is noted as 0. (C) The client is pregnant for the third time, and the first digit reflects the total number of pregnancies. She has had no full-term deliveries, because she delivered prior to 37 gestational weeks, so the second digit is recorded as 0. The third digit represents the number of preterm deliveries, and a twin pregnancy counts as only one delivery. She lost an earlier pregnancy prior to 20 gestational weeks, and the fourth digit reflects spontaneous or elective abortions. Lastly, the fifth digit indicates the number of children currently living, and she has no living children. (D) She is pregnant for the third time, and the first digit reflects the total number of pregnancies. In the previous two pregnancies, she delivered prior to 37 gestational weeks, thus having no full-term deliveries, which is indicated by the second digit. The fourth digit represents the total number of abortions, spontaneous or elective, and she reported a spontaneous abortion with her first pregnancy.

 

NEW QUESTION 58
A client with emphysema is placed on diuretics. In order to avoid potassium depletion as a side effect of the drug therapy, which of the following foods should be included in his diet?

A. LiverB. PotatoesC. CeleryD. Tomatoes

Answer: B

Explanation:
Explanation/Reference:
Explanation:
(A) Celery is high in sodium. (B) Potatoes are high in potassium. (C) Tomatoes are high in sodium. (D) Liver is high in iron.

 

NEW QUESTION 59
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