Nokea
A 15-month-old continually turns his cup upside down and shakes milk from the spout. The mother is convinced that he does this on purpose and asks the nurse what she should do. The nurse's response should be guided by the knowledge that:
- A. Toddlers often misbehave to get the attention of adults.
- B. Toddlers are able to use thought processes to experience events and reactions.
- C. Negative actions that are not immediately punished will be repeated.
- D. Manipulation of objects in their environment enables the toddler to learn about spatial relationships.
Correct Answer: D
Rationale: Toddlers explore spatial relationships through actions like shaking a cup, not necessarily to misbehave. Attention-seeking or punishment is less relevant.
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The home health nurse is providing long-term care to several clients. Which are examples of inappropriately crossing professional boundaries? Select all that apply.
- A. Accepting a birthday gift of a gold bracelet from a client
- B. Offering to pray together if a client so wishes
- C. Sending a sympathy card to family after a client dies
- D. Soliciting a wealthy client to invest in a company
- E. Staying after work hours and drinking wine with a client
Correct Answer: A,D,E
Rationale: Accepting expensive gifts (A), soliciting investments (D), and socializing with alcohol (E) violate professional boundaries. Offering to pray (B) is acceptable if client-initiated, and a sympathy card (C) is appropriate.
A nurse is caring for a client who is meeting with the palliative care team. After the meeting, the client's family asks for clarification about palliative care. Which statements about palliative care are accurate? Select all that apply.
- A. Palliative care focuses on quality of life and can be provided at any time
- B. Palliative care is only possible with a terminal diagnosis of ≤ 6 months
- C. Palliative care is provided by a multidisciplinary team
- D. Palliative care is another term for hospice care
- E. Palliative care provides relief from symptoms associated with chronic illnesses
Correct Answer: A,C,E
Rationale: Palliative care aims to improve quality of life and can be provided at any stage of illness (A). It involves a multidisciplinary team to address various needs (C). It also focuses on symptom relief for chronic illnesses (E). Palliative care is not limited to terminal diagnoses (B is incorrect) and is distinct from hospice care, which is specifically for end-of-life (D is incorrect).
The nurse is caring for a client with a tracheostomy who has an order to begin oral intake. Which of the following actions should the nurse take to decrease the client's risk for aspiration?
- A. Fully inflate the tracheostomy cuff before the client begins to eat.
- B. Encourage the client to use a straw when drinking fluids.
- C. Instruct the client to tilt the head back when swallowing
- D. Provide thickened liquids for the client.
Correct Answer: D
Rationale: Thickened liquids (D) reduce aspiration risk by slowing transit. Inflating the cuff (A) is not always necessary, straws (B) may increase risk, and tilting the head back (C) worsens aspiration.
The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina?
- A. My pain is deep in my chest behind my breast bone.
- B. When I sit up the pain gets worse.
- C. As I take a deep breath the pain gets worse.
- D. The pain is right here in my stomach area.
Correct Answer: A
Rationale: My pain is deep in my chest behind my breast bone. This describes the typical substernal pain of acute angina.
The nurse inserts a small bore nasogastric (NG) tube and prepares to initiate enteral feedings for a hospitalized client with laryngeal cancer. Which action should the nurse take first?
- A. Crush and administer medications
- B. Dilute enteral formula as prescribed
- C. Flush the tube with 30 mL of water
- D. Verify tube placement with an x-ray
Correct Answer: D
Rationale: Verifying NG tube placement with an x-ray (D) is the first step to ensure safety before feedings or medications. Other actions follow confirmation.