Nokea
A 16-month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her, and begins to cry. What would be the initial action by the nurse?
- A. Arrange for a change in client care assignments
- B. Explain that this behavior is expected
- C. Discuss the appropriate use of 'time-out'
- D. Explain that the child is in need of extra attention
Correct Answer: B
Rationale: The correct answer is to explain that this behavior is expected. At 16 months of age, children commonly experience separation anxiety, especially in unfamiliar environments like hospitals. It is important for the nurse to reassure the child and the parent that such behavior is normal. Option A is incorrect as there is no need to change client care assignments based on the child's behavior. Option C is not appropriate as discussing the use of 'time-out' is more relevant in behavior management for older children. Option D is incorrect as it does not address the underlying cause of the child's behavior related to separation anxiety.
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The nurse is caring for a 4-year-old child with a greenstick fracture. In explaining this type of fracture to the parents, the best response by the nurse should be that
- A. A child's bone is more flexible and can be bent 45 degrees before breaking
- B. Bones of children are more porous than adults and often have incomplete breaks
- C. Compression of porous bones produces a buckle or torus type break
- D. Bone fragments often remain attached by a periosteal hinge
Correct Answer: B
Rationale: The correct answer is B. Greenstick fractures are common in children because their bones are softer and more porous than adult bones, leading to incomplete breaks when force is applied. Choice A is incorrect as greenstick fractures are not due to bone flexibility but rather the porous nature of children's bones. Choice C is incorrect as it describes a buckle or torus type break, which is not characteristic of a greenstick fracture. Choice D is incorrect as greenstick fractures do not involve bone fragments remaining attached by a periosteal hinge.
With an alert of an internal disaster and the need for beds, the charge nurse is asked to list clients who are potential discharges within the next hour. Which client should the charge nurse select?
- A. An elderly client who has had type 2 diabetes for over 20 years, admitted with diabetic ketoacidosis 24 hours ago
- B. An adolescent admitted the prior night with Tylenol intoxication
- C. A middle-aged client with an internal automatic defibrillator and complaints of 'passing out at unknown times' admitted yesterday
- D. A school-age child diagnosed with suspected bacterial meningitis and was admitted at the change of shifts
Correct Answer: A
Rationale: The correct answer is A because a client with diabetic ketoacidosis (DKA) that is being well-managed and has shown improvement within 24 hours is more stable and can be considered for discharge sooner than those with more acute or unstable conditions. Choice B is incorrect as Tylenol intoxication may require further monitoring and intervention. Choice C is incorrect as a client with an automatic defibrillator and episodes of passing out needs careful evaluation and monitoring. Choice D is incorrect as suspected bacterial meningitis is a serious condition that typically requires a longer hospital stay for treatment and observation.
At a nursing staff meeting, there is a discussion of perceived inequities in weekend staff assignments. As a follow-up, what should the nurse manager do initially?
- A. Allow the staff to change assignments
- B. Clarify reasons for current assignments
- C. Help staff see the complexity of issues
- D. Facilitate creative thinking on staffing
Correct Answer: D
Rationale: Facilitating creative thinking on staffing is the most appropriate initial action for the nurse manager in addressing perceived inequities in weekend staff assignments. By encouraging creative thinking, the manager promotes innovative solutions and fosters a sense of ownership and collaboration among staff members. Choices A, B, and C are not the best initial steps in this situation. Allowing staff to change assignments may not address the underlying issues, clarifying reasons for current assignments may not resolve perceived inequities, and helping staff see the complexity of issues may not lead to actionable solutions.
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
- A. Gently rub the skin with a cotton swab to relieve itching
- B. Place the favorite books and push-pull toys in the crib
- C. Check every few hours for the next day or 2 for swelling in the baby's feet
- D. Turn the baby with the abduction stabilizer bar every 2 hours
Correct Answer: C
Rationale: The correct answer is to check every few hours for the next day or 2 for swelling in the baby's feet. Swelling in the baby's feet could indicate compromised circulation due to the cast, and frequent checks are necessary to ensure that there are no complications. Choices A, B, and D are incorrect because rubbing the skin with a cotton swab, placing favorite items in the crib, and turning the baby with the abduction stabilizer bar do not address the potential issue of compromised circulation and swelling in the baby's feet.
An activity designed to diagnose and treat a disease or condition in its earliest stages, before it becomes full-blown, would be classified as:
- A. primary prevention
- B. secondary prevention
- C. tertiary prevention
- D. health education
Correct Answer: B
Rationale: The correct answer is B, secondary prevention. Secondary prevention focuses on early diagnosis and intervention to prevent the progression of a disease or condition. This involves detecting and treating the illness in its early stages to reduce its impact. Choice A, primary prevention, aims to prevent the development of a disease or injury before it occurs by promoting healthy behaviors. Choice C, tertiary prevention, involves managing and improving the quality of life of individuals with established conditions to prevent complications and further deterioration. Choice D, health education, refers to providing information and promoting awareness about health issues to enable individuals to make informed decisions and adopt healthy behaviors.