Nokea
A 5-year-old child cries continually in her bed. Her parents have been unsuccessful in assisting her in expressing her feelings. Which activity should the nurse provide the child to assist her in expressing her feelings?
- A. Books with colorful pictures
- B. Music
- C. Riding toys
- D. Puppets
Correct Answer: D
Rationale: Puppets allow expression of feelings and fears that otherwise could not be directly communicated, helping the child articulate emotions.
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The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include:
- A. Ordering a full liquid diet for her
- B. Ordering five small meals for her
- C. Ordering a mechanical soft diet for her
- D. Ordering a puréed diet for her
Correct Answer: C
Rationale: A mechanical soft diet is easier to chew and swallow due to its consistent texture, making it appropriate before trying a puréed diet.
A client who has been receiving Urokinase (UPA) for deep vein thrombosis is noted to have dark brown urine in the urine collection bag. Which action should the nurse take immediately?
- A. Prepare an injection of vitamin K
- B. Irrigate the urinary catheter with 50 mL of normal saline
- C. Offer the client additional oral fluids
- D. Withhold the medication and notify the physician
Correct Answer: D
Rationale: Dark brown urine may indicate hematuria, a potential side effect of Urokinase, a thrombolytic agent. The nurse should withhold the medication and notify the physician immediately to assess for bleeding complications. Vitamin K is used for warfarin reversal, irrigation is inappropriate, and fluids won’t address the issue.
Which complaint is frequently expressed by a client with macular degeneration?
- A. Problems with activities requiring focused vision such as sewing
- B. Severe eye and face pain accompanied by nausea and vomiting
- C. Seeing halos around lights
- D. Veil-like loss of vision
Correct Answer: A
Rationale: Macular degeneration affects central vision, impairing activities like sewing or reading that require focused vision. Severe pain with nausea is typical of acute glaucoma, halos suggest cataracts or glaucoma, and veil-like vision loss is more associated with retinal detachment.
The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT,the nurse should:
- A. Apply a tourniquet to the client's arm
- B. Administer an anticonvulsant medication
- C. Ask the client if he is allergic to shellfish
- D. Apply a blood pressure cuff to the arm
Correct Answer: D
Rationale: A blood pressure cuff is applied to one limb during ECT to monitor for seizure activity (visible in the uncuffed limb). Tourniquets anticonvulsants and shellfish allergies are not relevant to ECT preparation.
On the first postpartal day, a client tells the nurse that she has been changing her perineal pads every 1/2 hour because they are saturated with bright red vaginal drainage. When palpating the uterus, the nurse assesses that it is somewhat soft, 1 fingerbreadth above the umbilicus, and midline. The nursing action to be taken is to:
- A. Gently massage the uterus until firm, express any clots, and note the amount and character of lochia
- B. Catheterize the client and reassess the uterus
- C. Begin IV fluids and administer oxytocic medication
- D. Administer analgesics as ordered to relieve discomfort
Correct Answer: A
Rationale: Gentle massage and expression of clots will let the fundus return to a state of firmness, allowing the uterus to function as the 'living ligature.' A distended bladder may promote uterine atony; however, after determining the bladder is distended, the nurse would have the client void. Catheterization is only done if normal bladder function has not returned. Oxytocic medications are ordered and administered if the uterus does not remain contracted after gentle massage and determining if the bladder is empty. The client is not complaining of discomfort or pain; therefore, analgesics are not necessary.