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A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse?
- A. Arrange to change client care assignments
- B. Explain that this behavior is expected
- C. Discuss the appropriate use of time-out
- D. Explain that the child needs extra attention
Correct Answer: B
Rationale: Explain that this behavior is expected. Fear of strangers is normal in toddlers and extends into the preschool period.
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A client is taking tranylcypromine (Parnate) and has received dietary instruction. Which of the following food selections would be contraindicated for this client?
- A. Fresh juice, carrots, vanilla pudding
- B. Apple juice, ham salad, fresh pineapple
- C. Hamburger, fries, strawberry shake
- D. Red wine, fava beans, aged cheese
Correct Answer: D
Rationale: Red wine, fava beans, and aged cheese contain tyramine and other vasopressors that can interact with MAOIs, potentially causing malignant hypertension.
The client has been vomiting for several days. Which blood gas values is he likely to have?
- A. pH=7.32; CO2=60; HCO3=30
- B. pH=7.32; CO2=33; HCO3=18
- C. pH=7.54; CO2=28; HCO3=22
- D. pH=7.54; CO2=32; HCO3=34
Correct Answer: C
Rationale: Prolonged vomiting causes metabolic alkalosis (high pH, low CO2) due to loss of stomach acid, matching pH=7.54, CO2=28, HCO3=22.
The nurse is assisting with the care of a client who has diabetic ketoacidosis. The nurse should recognize that it is a priority to
- A. gather supplies for an IV bolus of 0.9% sodium chloride
- B. prepare the client for an IV infusion of regular insulin
- C. request a prescription for potassium chloride
- D. obtain a urine specimen for urinalysis
Correct Answer: B
Rationale: In diabetic ketoacidosis, insulin administration is the priority to correct hyperglycemia and halt ketogenesis, addressing the underlying metabolic crisis.
During the client interview for a developmentally normal 18-month-old, the parent expresses concern about the small amount of food the child consumes. What is the nurse's priority intervention?
- A. Check the child for parasitic infections
- B. Consult a pediatric nutritionist for suspected eating disorder
- C. Notify the health care provider
- D. Reinforce teaching about the toddler's nutritional needs
Correct Answer: D
Rationale: Toddlers often eat small amounts due to slower growth rates and picky eating. Educating parents about normal toddler nutrition addresses concerns and promotes appropriate feeding practices.
What should be included in the care plan of a client who has myxedema?
- A. Encourage frequent rest periods
- B. Have the client do deep breathing and coughing exercises frequently
- C. Provide a cool environment
- D. Offer frequent high-calorie snacks
Correct Answer: A
Rationale: Myxedema (severe hypothyroidism) causes fatigue; frequent rest periods conserve energy. Deep breathing, cool environments, or high-calorie snacks are not prioritized.