Nokea
A nurse is caring for a 4-year-old child who is prescribed an intravenous medication preoperatively. Which of the following therapeutic play techniques is most appropriate when reinforcing the teaching for this procedure?
- A. Role play with another nurse the technique of IV placement and how the medication is infused.
- B. Read a story that explains the basics of how IVs are placed.
- C. Watch a movie narrated by nurses and children about IV placement.
- D. Explain the basic procedure and give the child IV supplies to play with minus the needle.
Correct Answer: D
Rationale: The correct answer is D because explaining the basic procedure and providing the child with IV supplies to play with (minus the needle) allows the child to familiarize themselves with the equipment in a non-threatening manner. This technique helps reduce anxiety and fear associated with the procedure. Role-playing may not be suitable for all children as it can be too abstract for a 4-year-old. Reading a story may not provide the hands-on experience needed to understand the procedure. Watching a movie may not be interactive enough for the child to actively engage in the learning process. Providing IV supplies for play is the most appropriate therapeutic play technique for a 4-year-old to prepare them for the IV placement procedure.
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A nurse is planning discharge for a client who is 3 days postpartum. Which of the following non pharmacological interventions should the nurse include in the plan of care for lactation suppression?
- A. Place warm, moist packs on the breast.
- B. Apply cabbage leaves to the breast.
- C. Wear a loose-fitting bra.
- D. Put green tea bags on the breasts.
Correct Answer: B
Rationale: The correct answer is B: Apply cabbage leaves to the breast. Cabbage leaves have been shown to help with lactation suppression due to their anti-inflammatory properties. Placing cabbage leaves on the breasts can help reduce milk supply by decreasing blood flow to the area. This method is safe, inexpensive, and easily accessible.
Choice A (Place warm, moist packs on the breast) is incorrect as warmth can actually stimulate milk production. Choice C (Wear a loose-fitting bra) is also incorrect as it does not directly address lactation suppression. Choice D (Put green tea bags on the breasts) is not effective for lactation suppression and may not be safe for the newborn if ingested.
A nurse is providing client/patient education to the mother of an 8-year-old child diagnosed with B-hemolytic streptococci infection (strep throat). The nurse emphasizes the importance of promptly starting and completing the entire course of antibiotics.
- A. alleviate painful swallowing to avoid complications of dehydration and malnutrition'
- B. prevent sinusitis or abscess formation on the pharyngeal or peri tonsillar areas'
- C. reduce the risk of anterior cervical lymphadenopathy'
- D. eliminate organisms that might initiate acute renal failure or rheumatic fever'
Correct Answer: D
Rationale: The correct answer is D. Completing the entire course of antibiotics for strep throat is crucial to eliminate the bacteria completely. Failure to do so may lead to potential complications like acute renal failure or rheumatic fever, which are serious systemic conditions associated with untreated strep infections. This is because streptococcal infections can trigger an immune response that can attack other parts of the body if not fully eradicated.
Choice A is incorrect because while completing the antibiotics may alleviate painful swallowing, the main emphasis should be on preventing systemic complications. Choice B is incorrect as sinusitis or abscess formation are not the primary concerns with strep throat. Choice C is incorrect as reducing anterior cervical lymphadenopathy is not the primary goal of antibiotic treatment for strep throat.
In summary, completing the full course of antibiotics is crucial to eliminate the bacteria and prevent serious complications such as acute renal failure or rheumatic fever.
A nurse is reinforcing teaching about accidental poisoning to a parent during a routine well-child visit.
- A. "I will give my child a dose of ipecac."'
- B. "I will place my child on her back."'
- C. "I will call the Poison Control Center."'
- D. "I will get my child to drink a full glass of water."'
Correct Answer: C
Rationale: The correct answer is C: "I will call the Poison Control Center." This is the best course of action in case of accidental poisoning as they provide expert advice on managing poison exposure. Calling them ensures prompt and accurate guidance to prevent further harm. Option A (ipecac) is not recommended anymore as it can cause more harm. Option B (placing the child on her back) is irrelevant to poisoning treatment. Option D (full glass of water) is not recommended as it can dilute the poison and may worsen the situation.
A nurse is holding an infant during a lumbar puncture for a suspicion of meningitis. The infant is in a sitting position with the buttocks at the edge of the table and the neck flexed, and the nurse is immobilizing the infant's arms and legs. Which assessment takes priority during the procedure?
- A. Circulation checks of the lower extremities
- B. Heart rate and crying pattern
- C. Chest expansion and diaphragm excursion
- D. Clarity of spinal fluid and level of consciousness
Correct Answer: C
Rationale: Chest expansion is critical due to the infant's position, which may limit breathing.
For a pregnant adolescent who is anemic, which foods should the nurse include in the client's dietary plan to increase iron levels?
- A. Milk and fish
- B. Chicken and cottage cheese
- C. Orange juice and apricots
- D. Pickles and peanut butter sandwiches
Correct Answer: C
Rationale: The correct answer is C: Orange juice and apricots. Orange juice is a good source of Vitamin C, which enhances iron absorption. Apricots are high in iron, helping to increase iron levels in the body. Milk and fish (choice A) contain little iron. Chicken and cottage cheese (choice B) are not significant sources of iron. Pickles and peanut butter sandwiches (choice D) lack iron and Vitamin C.