Nokea
A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is hospitalized for additional tests and to begin a course of chemotherapy designed to induce a remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone marrow test previously and is apprehensive about having another. Which of the following interventions will be most effective in relieving her anxiety?
- A. Explain what will take place and what she will see, feel, and hear.
- B. Remind her that she has had this procedure before and that it is nothing to be afraid of.
- C. Tell her not to worry about it, that it will be over soon and she can join her friends in the playroom.
- D. Give her a big hug and tell her that she is a big girl now and that she will do just fine.
Correct Answer: A
Rationale: Providing a detailed explanation of the procedure helps reduce anxiety by preparing the child for what to expect, addressing her previous experience.
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A 42-year-old client with bipolar disorder has been hospitalized on the inpatient psychiatric unit. She is dancing around, talking incessantly, and singing. Much of the time the client is anorexic and eats very little from her tray before she is up and about again. The nurse's intervention would be to:
- A. Confront the client with the fact that she will have to eat more from her tray to sustain her
- B. Try to get the client to focus on her eating by offering a detailed discussion on the importance of nutrition
- C. Let her have snacks and drinks anytime that she wants them because she will not eat at regular meal times
- D. Not expect the client to sit down for complete meals; monitor intake, offering snacks and juice frequently
Correct Answer: D
Rationale: The manic client's mood may easily change from euphoric to irritable. The nurse should avoid confrontation and let the client know what she can do, rather than what she cannot. Although helpful to refocus or redirect the manic client to discuss only one topic at a time, distractibility is very high and it's best to avoid long discussions. Manic clients have a tendency to manipulate persons in their environment. Staff should monitor intake, including at mealtime and snacks, and be consistent in their approach to meeting nutritional needs. Manic clients may not sit and eat complete meals, but they can carry foods and liquids from regular meals with them. Staff can monitor and give high-caloric and high-energy snacks and liquids.
The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:
- A. Phlebostatic axis
- B. Point of maximal impulse
- C. Erb's point
- D. Tail of Spence
Correct Answer: A
Rationale: The phlebostatic axis (located at the fourth intercostal space mid-axillary line) is the standard reference point for zeroing the manometer to accurately measure central venous pressure. The other options are incorrect anatomical landmarks.
The nurse is teaching a client with hypertension about dietary modifications. Which food choice indicates a need for further teaching?
- A. Fresh apple
- B. Baked chicken
- C. Canned soup
- D. Steamed broccoli
Correct Answer: C
Rationale: Canned soup is high in sodium, which exacerbates hypertension, indicating a need for further teaching. Apple (A), chicken (B), and broccoli (D) are low-sodium and appropriate.
Which of the following is a characteristic of an ominous periodic change in the fetal heart rate?
- A. A fetal heart rate of 120-130 bpm
- B. A baseline variability of 6-10bpm
- C. Accelerations in FHR with fetal movement
- D. A recurrent rate of 90-100 bpm at the end of the contractions
Correct Answer: D
Rationale: A recurrent fetal heart rate of 90-100 bpm at the end of contractions (late decelerations) is ominous indicating fetal hypoxia from uteroplacental insufficiency. Normal heart rate (120-130) variability and accelerations are reassuring findings.
The nurse is caring for a client with a history of a hiatal hernia who is receiving Propulsid (cisapride). The nurse should monitor the client for:
- A. Arrhythmias
- B. Hypotension
- C. Constipation
- D. Weight gain
Correct Answer: A
Rationale: Cisapride can prolong the QT interval, risking arrhythmias, requiring cardiac monitoring. Hypotension, constipation, and weight gain are not primary side effects.