Nokea
A 9-year-old child is hospitalized in traction for 2 months after a car accident. Which intervention should the nurse plan to use to best promote psychosocial development?
- A. Providing a music player
- B. Tutoring to keep the child up with schoolwork
- C. Providing a phone for calling family and friends
- D. Placing computer games, a television, and videos at the bedside
Correct Answer: B
Rationale: The developmental task of the school-age child is industry versus inferiority. The child achieves success by mastering skills and knowledge. Maintaining schoolwork provides for accomplishment and prevents feelings of inferiority that may be caused by lagging behind the rest of the class. The other options provide diversion and are of lesser importance for a child of this age.
You may also like to solve these questions
The nurse is caring for a client with a diagnosis of a mild cerebral bleed resulting from a small cerebral aneurysm rupture. The client reports feeling anxious and restless about family visiting soon. Which comment by the client should assist the nurse in identifying the reason for the anxiety?
- A. My son came to visit me yesterday.
- B. At least I can speak and answer questions.
- C. I have a problem turning my neck to the side.
- D. Look at me, I can no longer be the head of my family.
Correct Answer: D
Rationale: With a mild bleed from a cerebral aneurysm rupture the client usually remains alert but has nuchal rigidity with possible neurological deficits, depending on the area of the bleed. Because these clients remain alert, they are acutely aware of the neurological deficits and frequently have some degree of body image disturbance. Option 4 alludes to the client's self-perception about not being able to be the head of the family now. The remaining client statements are unrelated to anxiety and restlessness.
A charge nurse observes an unlicensed assistive personnel (UAP) talking in an unusually loud voice to a client with schizophrenia experiencing delirium. Which priority action should the charge nurse take?
- A. Enter the room and inform the client that everything is all right.
- B. Speak to the UAP immediately while in the client's room to solve the problem.
- C. Ensure the client's safety, calmly ask the UAP to step outside the room, and inform the UAP that her or his voice was unusually loud.
- D. Explain to the UAP that speaking so loudly is tolerated only if the client is talking loudly and the UAP needs to get the client's attention.
Correct Answer: C
Rationale: The nurse must ascertain that the client is safe and then discuss the matter with the UAP in an area away from the hearing of the client. If the client hears the conversation, the client may become more confused or agitated. The remaining options are incorrect actions for this situation.
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?
- A. Mode of transmission
- B. Portal of entry
- C. Reservoir
- D. Portal of exit
Correct Answer: A
Rationale: When the nurse rolls contaminated gloves inside-out, they are manipulating the mode of transmission in the chain of infection. The gloves, which are contaminated, act as a vehicle for transferring pathogens from the reservoir's portal of exit to a potential portal of entry. Choices B, C, and D are incorrect because the action of rolling contaminated gloves does not directly relate to the portal of entry, reservoir, or portal of exit in the chain of infection.
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?
- A. The occurrence of any episodes of sleep apnea
- B. The child's blood pressure, pulse, and respirations
- C. Length of rapid eye movement (REM) sleep that the child is experiencing
- D. Description of the family's home environment
Correct Answer: D
Rationale: When a school-age child has difficulty going to sleep and waking up in the morning, it is important to assess the family's home environment. This includes factors such as bedtime rituals, noise levels, lighting, use of electronic devices, and overall sleep hygiene practices. Understanding the home environment can help identify issues that may be contributing to the child's sleep problems and guide the development of a plan to promote better sleep habits. Options A, B, and C are less relevant in this scenario. Sleep apnea typically causes daytime fatigue rather than resistance to bedtime. Assessing vital signs like blood pressure, pulse, and respirations is unlikely to provide insights into the child's sleep patterns. Monitoring REM sleep duration is not practical in a clinical setting and may not directly address the reported sleep issues in this case.
A client has an initial positive result of an enzyme-linked immunosorbent assay (ELISA) test for human immunodeficiency virus (HIV). The client begins to cry and asks the nurse what this means. Which knowledge should the nurse use to provide support to the client?
- A. The client is HIV positive, but the client's CD4 cell count is high.
- B. The client is HIV positive, but the disease has been detected early.
- C. There are occasional false-positive readings with this test; results can be verified by repeating it one more time.
- D. False-positive results can occur, and more testing is needed before diagnosing the client as being HIV positive.
Correct Answer: D
Rationale: If the client tests positive for HIV with the ELISA test, the test is repeated because of the potential for a false-positive result (e.g., from a recent influenza or hepatitis B vaccine) or a false-negative result if drawn too early after infection. If the test is positive a second time, the Western blot (a more specific test) is done to confirm the finding. The client is not diagnosed as HIV positive unless the Western blot is positive. Some laboratories also run the Western blot a second time with a new specimen before making a final determination.