Nokea
A 16-year-old adolescent is admitted to the hospital with a diagnosis of meningitis. The nurse notes that the client has a severe headache and photophobia. What is the nurse's priority action?
- A. Administer prescribed pain medication
- B. Place the client in a dark, quiet room
- C. Notify the healthcare provider
- D. Encourage the client to rest
Correct Answer: B
Rationale: The priority action for the nurse when a client with meningitis presents with a severe headache and photophobia is to place the client in a dark, quiet room. This intervention helps reduce stimuli that can exacerbate symptoms such as headache and photophobia. Creating a calm environment can provide relief and promote comfort for the client while also supporting their recovery. Administering pain medication may be necessary but ensuring a suitable environment takes precedence. Notifying the healthcare provider is important but is not the immediate priority. Encouraging rest is beneficial, but creating an appropriate environment to alleviate symptoms is the initial essential step.
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The nurse is assessing a 3-month-old infant who was brought to the clinic by the parents due to concerns about the infant's feeding. The parents report that the infant has been vomiting after every feeding and has not gained any weight. What should the nurse assess first?
- A. Evaluate the infant's feeding technique
- B. Check the infant's hydration status
- C. Measure the infant's abdominal circumference
- D. Review the infant's growth chart
Correct Answer: B
Rationale: Assessing hydration status is crucial in an infant who is vomiting frequently, as dehydration can quickly become a serious issue. In this scenario, the infant's inability to retain feeds and lack of weight gain may indicate a potential risk of dehydration, making it essential to prioritize checking the infant's hydration status to prevent complications. Evaluating the feeding technique (Choice A) could be important but is secondary to addressing potential dehydration. Measuring the abdominal circumference (Choice C) and reviewing the growth chart (Choice D) are not the priority in this situation where dehydration is a primary concern.
Which statement by a school-aged client going to summer camp indicates the best understanding of the mode of transmission of Lyme disease?
- A. I'll cover my mouth with a wet cloth if there's too much dust blowing.
- B. Cuts and scrapes need to be washed out and covered right away.
- C. I'm not going to swim where the water is standing still or feels too hot.
- D. I have to wear long sleeves and pants when we're hiking around the pond.
Correct Answer: D
Rationale: The correct answer is D. Wearing long sleeves and pants helps prevent tick bites, which can transmit Lyme disease. Ticks carrying Lyme disease are often found in wooded or grassy areas, so covering exposed skin can reduce the risk of being bitten by an infected tick. Choices A, B, and C do not address the specific mode of transmission of Lyme disease through tick bites, making them incorrect.
The nurse is caring for a 3-year-old child who has been recently diagnosed with cystic fibrosis. Which discharge instruction by the nurse is most important to promote pulmonary function?
- A. Chest physiotherapy should be performed before meals and at bedtime
- B. Cough suppressants can be used up to four times a day for relief
- C. Oxygen should be given through a nasal cannula between 4-6 L/min
- D. Exercise is discouraged in order to preserve pulmonary vital capacity
Correct Answer: B
Rationale: In cystic fibrosis, thick mucus obstructs the airways, making it difficult to clear from the lungs. Cough suppressants can help reduce the discomfort associated with persistent coughing, allowing the child to cough more effectively to clear the mucus, thus promoting pulmonary function. Chest physiotherapy, not exercise, helps mobilize the mucus. Oxygen therapy may be needed but is not the most important for promoting pulmonary function in this case.
The healthcare provider is developing the plan of care for a hospitalized child with von Willebrand disease. What priority nursing intervention should be included in this child's plan of care?
- A. Reduce exposure to infection.
- B. Eliminate contact with cold objects.
- C. Guard against bleeding injuries.
- D. Reduce contact with other children.
Correct Answer: C
Rationale: Children with von Willebrand disease have a deficiency in a clotting protein, putting them at risk of bleeding episodes. The priority nursing intervention for a child with von Willebrand disease is to guard against bleeding injuries to prevent excessive bleeding or hemorrhage. Choices A, B, and D are not the priority interventions for von Willebrand disease. While reducing exposure to infection is important for any hospitalized child, it is not the priority for von Willebrand disease. Eliminating contact with cold objects is more relevant for conditions like Raynaud's disease. Reducing contact with other children is not a specific priority related to managing von Willebrand disease.
The parents of a 15-month-old boy tell the nurse that they are concerned because their son brings his spoon to his mouth but does not turn it over. What action should the nurse implement first?
- A. Discuss the possibility of a referral to a specialist
- B. Question the parents about their concern
- C. Advise the parents on proper spoon handling techniques for the child
- D. Recommend extending mealtimes to allow the child to finish eating
Correct Answer: B
Rationale: The initial action for the nurse is to question the parents about their concerns. By doing so, the nurse can gather more information to understand the situation better. This helps in determining if the child's behavior is within normal development or if further action or referrals are necessary. Choice A is incorrect as it jumps to a specialist referral without fully assessing the situation first. Choice C is also incorrect because assuming the parents need advice on proper spoon handling techniques may not be the case. Choice D is incorrect as it does not address the core concern raised by the parents.