Nokea
A 3-year-old female is hospitalized for a femur fracture. As her nurse, what nursing action would help foster the child's sense of autonomy?
- A. Allow the child to choose what time to take her oral antibiotics.
- B. Allow the child to have a doll for medical play.
- C. Allow the child to administer her own dose of Keflex (cephalexin) via oral syringe.
- D. Allow the child to watch age-appropriate videos.
Correct Answer: B
Rationale: Allowing preschoolers to participate in actions for which they are capable is an excellent way to enhance their sense of autonomy.
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A medical student observes that infants cry in response to another infant's cry. The MOST appropriate answer is that it represents
- A. an early sign of empathy development
- B. a sign of good hearing
- C. a startle reflex
- D. an early sign of fear development
Correct Answer: A
Rationale: Infants crying in response to others may indicate early empathy development.
At the present time, the best treatment for cancer is complete __________ before metastasis occurs:
- A. Chemotherapy
- B. Radiation
- C. Surgical removal
- D. All of the above
Correct Answer: C
Rationale: The best treatment for cancer at the present time is complete surgical removal before metastasis occurs. Surgery is often the most effective method to remove the primary tumor and eliminate cancer cells in the affected area. While chemotherapy and radiation therapy are important in treating cancer, surgical removal of the tumor provides the best chance for complete eradication of cancer cells, especially if it is done before the cancer has spread to other parts of the body.
The nurse is caring for a newborn receiving an exchange transfusion for hemolytic disease. Assessment of the newborn reveals slight respiratory distress and tachycardia. Which should the nurse's first action be?
- A. Notify practitioner.
- B. Stop the transfusion.
- C. Administer calcium gluconate.
- D. Monitor vital signs electronically.
Correct Answer: B
Rationale: Slight respiratory distress and tachycardia in a newborn during an exchange transfusion may indicate a possible transfusion reaction or overload. The first action the nurse should take is to stop the transfusion to prevent any further complications and assess the newborn's condition. After stopping the transfusion, the nurse can then take appropriate steps such as notifying the practitioner, administering medications, or providing supportive care as needed.
A school nurse is conducting vision and hearing testing on fifth-grade children. Which level of prevention is the nurse demonstrating?
- A. Primary
- B. Secondary
- C. Tertiary
- D. Health promotion
Correct Answer: B
Rationale: The school nurse conducting vision and hearing testing on fifth-grade children is demonstrating the secondary level of prevention. Secondary prevention involves identifying and treating health conditions early to prevent their progression. In this scenario, the nurse's aim is to detect any existing vision or hearing problems in the children at an early stage so that appropriate interventions can be initiated to prevent further impairment or complications. This aligns with the goals of secondary prevention, which focuses on early detection, prompt intervention, and minimizing the impact of a health condition.
Mrs. Baker was instructed by the nurse on foods to encourage her child's diet concerning the latter's iron deficiency anemia; which of the following if stated by the mother would indicate the need for further instruction?
- A. Fish
- B. Lean meats
- C. Whole-grain breads
- D. Yellow vegetables
Correct Answer: D
Rationale: Yellow vegetables do not contain a significant amount of iron compared to the other options provided (fish, lean meats, and whole-grain breads). Therefore, if Mrs. Baker indicates that she plans to focus on yellow vegetables to address her child's iron deficiency anemia, further instruction would be necessary to help her choose more iron-rich sources of food to improve her child's condition.