Nokea
A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful?
- A. Examine the 4 year old first.
- B. Provide time for play and becoming acquainted.
- C. Have the mother leave the room with one child, and examine the other child privately.
- D. Examine painful areas first to get them 'over with.'
Correct Answer: B
Rationale: The 6 month old should be examined first. If several children will be examined, begin with the most cooperative and less anxious child to provide modeling. Providing time for play and getting acquainted minimizes stress and anxiety associated with assessment of body parts. Children generally cooperate best when their mother remains with them. Painful areas are best examined last and will permit maximum accuracy of assessment.
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A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of:
- A. Afterbirth pains
- B. Constipation
- C. Cystitis
- D. A hematoma of the vagina or vulva
Correct Answer: D
Rationale: Afterbirth pains are a common complaint in the postpartum client, but they are located in the uterus. Constipation may cause rectal pressure but is not usually associated with 'severe pain.' Cystitis may cause pain, but the location is different. Hematomas are frequently associated with severe pain and pressure. Further assessments are indicated for this client.
A client with a history of asthma is admitted with complaints of wheezing. The nurse should give priority to:
- A. Administering bronchodilators
- B. Monitoring blood pressure
- C. Administering pain medication
- D. Monitoring temperature
Correct Answer: A
Rationale: Bronchodilators relieve wheezing in asthma by relaxing airway smooth muscles, improving airflow.
Upon admission to the hospital, a client reports having "the worst headache I've ever had." The nurse should give the highest priority to which action?
- A. Administering pain medication
- B. Starting oxygen
- C. Performing neuro checks
- D. Inserting a Foley catheter
Correct Answer: C
Rationale: A severe headache may indicate a neurological emergency (e.g., subarachnoid hemorrhage). Neuro checks (C) assess for deterioration. Pain medication (A), oxygen (B), and Foley (D) are secondary.
A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:
- A. Airway obstruction
- B. Communication impairment
- C. Pain management
- D. Infection risk
Correct Answer: C
Rationale: Pain management is a priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy due to the surgical incision and tissue trauma, which can cause significant discomfort. Effective pain control is essential to promote recovery and patient comfort.
The nurse is explaining to an adult client with an ulcer diagnosis about the drug esomeprazole (Nexium). Which side effect(s) will the nurse want to include in the discussion?
- A. Headache
- B. Diarrhea
- C. Flushing
- D. Dizziness
- E. Nausea
Correct Answer: A, B, D, E
Rationale: Esomeprazole side effects include headache (A), diarrhea (B), dizziness (D), and nausea (E). Flushing (C) is not a common side effect.