Nokea
A child is admitted with suspected epiglottitis. Which action is not a part of the nursing care?
- A. Checking the vital signs
- B. Assessing the throat with a tongue blade
- C. Administering oxygen as needed
- D. Administering IV antibiotics
Correct Answer: B
Rationale: Assessing the throat with a tongue blade is contraindicated in suspected epiglottitis as it may trigger airway obstruction. Vital signs oxygen and antibiotics are appropriate interventions.
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The nurse is caring for a client who is receiving terbutaline for preterm labor. Which side effect should the nurse monitor for?
- A. Maternal bradycardia
- B. Fetal hypoglycemia
- C. Maternal tachycardia
- D. Fetal macrosomia
Correct Answer: C
Rationale: Terbutaline a beta-agonist tocolytic commonly causes maternal tachycardia due to its stimulatory effects on the cardiovascular system. Maternal bradycardia fetal hypoglycemia and macrosomia are not associated side effects.
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.
The pediatric nurse charts that the parents of a 4-year-old child are very anxious. Which observation would indicate to the nurse unhealthy coping by these parents:
- A. Discussing their needs with the nursing staff
- B. Discussing their needs with other family members
- C. Seeking support from their minister
- D. Refusing to participate in the child's care
Correct Answer: D
Rationale: (A, B, C) These methods are healthy ways of dealing with anxiety. Participation minimizes feelings of helplessness and powerlessness. It is important that parents have accurate information and that they seek support from sources available to them.
The nurse is caring for a client with a diagnosis of postpartum depression. Which symptom is most likely to be present?
- A. Persistent sadness
- B. Fever and chills
- C. Uterine tenderness
- D. Foul-smelling lochia
Correct Answer: A
Rationale: Postpartum depression is characterized by persistent sadness and low mood. Fever uterine tenderness and foul-smelling lochia suggest infection not depression.
The nurse is caring for a client with a history of schizophrenia. Which medication is most likely to be prescribed?
- A. Fluoxetine (Prozac)
- B. Risperidone (Risperdal)
- C. Clonazepam (Klonopin)
- D. Bupropion (Wellbutrin)
Correct Answer: B
Rationale: Risperidone, an antipsychotic, is used to treat schizophrenia by managing hallucinations and delusions. Fluoxetine and bupropion are antidepressants, and clonazepam is for anxiety.