Nokea
A four-month-old child is admitted with a tentative diagnosis of meningitis.
- A. What is the most important nursing action during a lumbar puncture for a four-month-old with suspected meningitis?
- B. Appropriately restrain the child.
- C. Instruct the parents about the procedure.
- D. Provide support to the child.
- E. Elevate the head of the bed.
Correct Answer: A
Rationale: Restraining the child during a lumbar puncture prevents movement, reducing the risk of spinal trauma. Parental instruction and emotional support are important but secondary, and elevating the head is inappropriate for positioning.
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A husband and wife meet at the mental health clinic to make an appointment for family therapy. Suddenly, the wife begins to sob loudly. As the nurse approaches, the husband says, 'I guess we just don't get along.' Which of the following responses by the nurse is MOST appropriate?
- A. Your wife seems to be upset by the situation.
- B. Perhaps you should both go home now.
- C. Try to think about what precipitated her crying.
- D. The situation is difficult for both of you.
Correct Answer: D
Rationale: Acknowledging the emotional impact on both spouses fosters therapeutic communication without judgment. Options A, B, and C are less effective: A focuses only on the wife, B dismisses the situation, and C may provoke defensiveness.
Which of the following findings is associated with right-sided heart failure?
- A. Shortness of breath
- B. Nocturnal polyuria
- C. Daytime oliguria
- D. Crackles in the lungs
Correct Answer: B
Rationale: Nocturnal polyuria occurs in right-sided heart failure due to fluid redistribution at night. Shortness of breath and crackles are more typical of left-sided failure. Oliguria is not specific.
The nurse is assessing a client immediately after an exploratory laparotomy. Which of the following nursing observations would relate to the complication of inTest inal obstruction?
- A. Protruding soft abdomen with frequent diarrhea.
- B. Distended abdomen with ascites.
- C. Minimal bowel sounds in all four quadrants.
- D. Distended abdomen with complaints of pain.
Correct Answer: D
Rationale: if an obstruction is present, the abdomen will become distended and painful
A laboring woman who has dystocia is receiving oxytocin. The nurse observes a contraction lasting 90 seconds. What should the nurse do first?
- A. Slow down the rate of the oxytocin
- B. Turn the woman on her left side
- C. Give the woman oxygen
- D. Stop the oxytocin
Correct Answer: D
Rationale: Contractions longer than 60-90 seconds risk fetal hypoxia; stopping oxytocin immediately reduces uterine stimulation, prioritizing fetal safety.
The nurse is caring for a client with a history of hypertension who is receiving hydralazine (Apresoline) 25 mg PO tid. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg
- B. Heart rate of 100 bpm
- C. Chest pain and shortness of breath
- D. Mild headache
Correct Answer: C
Rationale: Chest pain and shortness of breath suggest angina or lupus-like syndrome, serious hydralazine side effects. Options A, B, and D are less urgent: BP is normal, tachycardia is mild, and headache is common.