Nokea
A nurse is caring for a 2-year-old with a new diagnosis of strabismus. Which intervention should the nurse anticipate?
- A. Correction with laser surgery
- B. Eye drops in the affected eye
- C. Measurement of intraocular pressure
- D. Patching of the unaffected eye
Correct Answer: D
Rationale: Patching the unaffected eye strengthens the weaker eye in strabismus by forcing its use, a common non-surgical treatment in children. Laser surgery is not typically used, eye drops are irrelevant, and intraocular pressure measurement is for glaucoma, not strabismus.
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According to the ANA Code of Ethics for Nurses, professional nurses have an ethical obligation to:
- A. clients (patients).
- B. the profession of nursing.
- C. provide high-quality care.
- D. all of the above.
Correct Answer: D
Rationale: The ANA Code of Ethics encompasses obligations to clients, the profession, and delivering high-quality care, ensuring comprehensive ethical practice. Coordinated Care
A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day care as soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this child?
- A. All lesions crusted
- B. Elevated temperature
- C. Rhinorrhea and coryza
- D. Presence of vesicles
Correct Answer: A
Rationale: All lesions crusted. The child is no longer contagious when all lesions are crusted over.
All of the following are common reasons that nurses are reluctant to delegate except:
- A. lack of self-confidence.
- B. desire to maintain authority.
- C. confidence in subordinates.
- D. getting trapped in the 'I can do it better myself' mindset.
Correct Answer: C
Rationale: Confidence in subordinates encourages delegation, while lack of confidence, desire for control, or perfectionism are common barriers to delegating tasks. Coordinated Care
A spouse brings a client with a history of previous suicide attempts to the emergency department due to erratic behavior and expressions of hopelessness. When the triage nurse asks if the client is having suicidal thoughts, the client shrugs their shoulders. What action should the triage nurse take?
- A. Document that the client is not currently suicidal
- B. Have the client remain in triage and frequently observe for changes
- C. Place the client on one-to-one observation
- D. Return the client to the waiting room with their spouse
Correct Answer: C
Rationale: Given the history of suicide attempts and current hopelessness, a noncommittal response like shrugging suggests a high suicide risk. One-to-one observation ensures safety. Documenting no suicidality is inaccurate, frequent observation is insufficient, and returning to the waiting room is unsafe.
A young child is admitted for treatment of lead poisoning. The nurse recognizes that the most serious effect of chronic lead poisoning is
- A. Central nervous system damage
- B. Moderate anemia
- C. Renal tubule damage
- D. Growth impairment
Correct Answer: A
Rationale: Central nervous system damage. The most serious consequences of chronic lead poisoning occur in the central nervous system, leading to intellectual deficits or even death.