Strategy: Picture each infant.

(1) unable to sit unsupported until 8 months

(2) unable to sit unsupported until 8 months
(3) correctcan pull self up and assume a sitting position at 8 months, can say few
words
(4) would be able to say 35 words in addition to dada and mama
71. The nurse in the outpatient clinic teaches a client with a sprained right
ankle to walk with a cane. What behavior, if demonstrated by the client,
would indicate that teaching was effective?
1.
2.
3.
4.

The
The
The
The

client
client
client
client

advances
holds the
advances
holds the

the cane 18 inches in front of her foot with each step.

cane in her left hand.
her right leg, then her left leg, and then the cane.
cane with her elbow flexed 60.

Strategy: Teaching was effective indicates a correct behavior.

(1) should advance cane 610 inches with body weight on both legs
(2) correctshould hold cane on strong side, widens base of support, reduces stress
on affected side
(3) should advance cane, weaker leg, stronger leg
(4) should flex no more than 30
72. The nurse is performing triage on a group of clients in the emergency
department. Which of the following clients should the nurse see FIRST?
1. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a
rusty metal can.
2. A 19-year-old with a fever of 103.8F (39.8C) who is able to identify her sister
but not the place
and time.
3. A 49-year-old with a compound fracture of the right leg who is complaining of
severe pain.
4. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of
470 mg/dL.
Strategy: Identify the least stable client.
(1) no indication of hemorrhage, will require a tetanus shot
(2) correctdisoriented, requires immediate assessment to determine underlying
cause
(3) splint, cover wound with sterile dressing, check temperature, color, sensation,
give narcotic
(4) hyperglycemic, give IV fluid, regular insulin
73. If a client develops cor pulmonale (right-sided heart failure), the nurse
would expect to observe
1.
2.
3.
4.

increasing respiratory difficulty seen with exertion.

cough productive of a large amount of thick, yellow mucus.
peripheral edema and anorexia.
twitching of extremities.