Nokea
The nurse is interviewing a 5-year-old client who is reporting abdominal pain. Which of the following are effective strategies for communicating with the child? Select all that apply.
- A. Allow the child to describe the symptoms
- B. Ask closed-ended questions to obtain pertinent information
- C. Explain procedures to match the child's concrete thinking
- D. Interview the child separately from the parents
- E. Maintain an eye-level position when speaking with the child
Correct Answer: A,C,E
Rationale: Allowing the child to describe symptoms encourages open communication, and interviewing separately reduces parental influence, ensuring accurate reporting. Closed-ended questions may limit a young child’s ability to express complex symptoms.
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There have been several clients recently who have fallen in the long-term care facility. The nurse would like to reduce the number of falls. Which action is likely to do the most to help prevent falls?
- A. Ask the nursing assistants to watch the clients more closely.
- B. Restrain clients who cannot walk independently.
- C. Provide call bells so the clients can carry with them when they walk.
- D. Keep beds in the lowest position unless the nurse is performing care for the client.
Correct Answer: D
Rationale: Low bed height minimizes fall injury risk, a key prevention strategy. Closer watching, restraints, or call bells are less effective or restrictive.
When interviewing the parents of a child with asthma, it is most important to assess the child's environment for what factor?
- A. Household pets
- B. New furniture
- C. Lead based paint
- D. Plants such as cactus
Correct Answer: A
Rationale: Animal dander is a very common allergen affecting persons with asthma. Other triggers may include pollens, carpeting and household dust.
What nursing action is essential when oxygen is ordered for a client who is living at home?
- A. Assist the client and family in checking all electrical appliances in the vicinity for frayed cords.
- B. Encourage the client and family to purchase fire extinguishers.
- C. Remove electrical devices from the room where oxygen is in use.
- D. Encourage the client and family to carpet the client's room.
Correct Answer: A
Rationale: Checking for frayed cords reduces fire risk, as oxygen supports combustion. Extinguishers are secondary, removing devices is impractical, and carpeting increases static sparks.
A client with advanced Alzheimer’s dementia is admitted to a skilled nursing facility for delirium. The health care provider prescribes ambulation with partial weight bearing. Which would be the most appropriate method for the nurse to use to transfer this client safely?
- A. 1-person stand and pivot with a gait belt and walker
- B. 2-person full-body sling lift
- C. 2-person motorized standing-assist lift
- D. 2-person stand and pivot with a gait belt and walker
Correct Answer: D
Rationale: A 2-person stand and pivot with a gait belt and walker ensures safety for a client with dementia and partial weight bearing, accounting for confusion and weakness. One-person transfer risks falls, and lifts are excessive for ambulation.
An 85-year-old woman is hospitalized with a fractured hip. She complains to the LPN/LVN that she feels something is wrong and her chest hurts. The nurse notes the client has tachypnea. What should the nurse do immediately?
- A. Administer oxygen
- B. Take vital signs
- C. Elevate the head of the bed
- D. Give aspirin
Correct Answer: B
Rationale: Chest pain and tachypnea suggest a possible pulmonary embolism post-hip fracture; taking vital signs provides critical data for immediate assessment.