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The nurse is planning care for an 11-year-old child with attention deficit hyperactivity disorder who is hospitalized for surgical treatment of a fractured femur. What is the priority nursing action?
- A. Create a structured and consistent environment with a daily schedule
- B. Give the child a written schedule of activities
- C. Provide a verbal explanation of what to expect during hospitalization
- D. Restrict visitors while the child is hospitalized
Correct Answer: A
Rationale: A structured environment (A) supports ADHD management by reducing overstimulation and providing predictability, critical for a hospitalized child. Written schedules (B) and verbal explanations (C) are secondary, and restricting visitors (D) is unnecessary.
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The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse most likely to find?
- A. Complaints of numbness and tingling in feet
- B. Wheezing noted when lung sounds auscultated
- C. Excessive perspiration
- D. Difficulty sleeping
Correct Answer: A
Rationale: Complaints of numbness and tingling in feet. A child who has unusual neurologic signs or symptoms, neuropathy, footdrop, or anemia that cannot be attributed to other causes may be suffering from lead poisoning. This most often occurs when a child ingests or inhales paint chips from lead-based paint or dust from remodeling in older buildings.
A 4-year-old admitted with Wilms tumor is scheduled for a right nephrectomy in the morning. Which nursing action is a priority pre-operatively?
- A. Assessment of the child's emotional maturity level
- B. Auscultating for adventitious breath sounds
- C. Monitoring blood pressure closely
- D. Reinforcing instructions not to palpate the abdomen
Correct Answer: D
Rationale: Avoiding abdominal palpation (D) prevents tumor rupture in Wilms tumor, a critical pre-operative priority. Emotional assessment (A), lung sounds (B), and BP monitoring (C) are important but secondary.
The nurse is planning an approach to decrease urinary incontinence in an elderly client. Which activity will do the most to help prevent incontinence?
- A. Restrict fluids until continence has been achieved and then hydrate well.
- B. Offer the bedpan at two-hour intervals during the day and every four hours at night.
- C. Encourage the client to ambulate frequently and have the client do deep breathing exercises.
- D. Encourage fluids during the day and offer the bedpan every two hours.
Correct Answer: D
Rationale: Adequate hydration and frequent toileting (every two hours) promote bladder health and reduce incontinence. Fluid restriction or unrelated exercises are ineffective.
Which of the following herbal supplements pose an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery? Select all that apply.
- A. Black cohosh
- B. Garlic
- C. Ginger
- D. Ginkgo biloba
- E. Hawthorn
Correct Answer: B,C,D
Rationale: Garlic (B), ginger (C), and ginkgo biloba (D) have antiplatelet effects, increasing bleeding risk. Black cohosh (A) and hawthorn (E) do not significantly affect bleeding.
A client was admitted to the psychiatric unit after refusing to get out of bed. In the hospital the client talks to unseen people and voids on the floor. The nurse could best handle the problem of voiding on the floor by
- A. Requiring the client to mop the floor
- B. Restricting the client's fluids throughout the day
- C. Withholding privileges each time the voiding occurs
- D. Toileting the client more frequently with supervision
Correct Answer: D
Rationale: Toileting the client more frequently with supervision. This approach addresses the physical need in a client with altered thought processes.