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A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent.
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency that can cause rapid airway obstruction. Intubation ensures a secure airway and oxygenation. Throat culture (B) is not a priority in this acute situation. Suctioning (C) can provoke spasm and worsen obstruction. Cool mist tent (D) does not address the immediate need for securing the airway.
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A nurse is caring for a recently admitted 18-year-old client:
Nurses' Notes
1000:
Client admitted to behavioral health unit for prolonged weight loss and refusal to eat. Client collapsed at school. The client's parents were called. They contacted the primary care provider, who arranged for a direct admission.
Weight 37.2 kg (82 lb)
Height 157.5 cm (62 inches)
BMI 15
1200:
Client observed during noon meal. Client pushed food around the plate. Intake 10% of meal. Offered nutritional supplement. Client declined. Reports feeling anxious due to admission and mealtime. Client states, "I cannot eat this with you watching me."
1500:
Snack provided. Client observed throwing snack into the trash can. When realized they had been observed, they admitted to their action and asked for a second snack. Client ate 10% of their snack.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Provide the client, with foods that have a variety of textures, Accept the client’s belief about "forbidden" foods, Focus on the client’s underlying feelings of lack of control, Encourage the client to limit fasting, Provide a structured meal environment.
- B. Bulimia Nervosa, Binge eating disorder, Anorexia nervosa, Avoidant/restrictive food intake disorder.
- C. Cardiac function with ECG, Weight on a daily basis, Calcium level, Vital signs every 8 hr, Behavior 15min after meals.
Correct Answer: A[2,4],B[2],C[0,4]
Rationale: Action to Take: Provide the client with foods that have a variety of textures, Encourage the client to limit fasting; Potential Condition: Anorexia nervosa; Parameter to Monitor: Weight on a daily basis, Behavior 15 minutes after meals.
Rationale: In anorexia nervosa, the client typically has a fear of gaining weight, leading to restrictive eating habits. Providing foods with different textures can help normalize eating habits and improve nutrition. Encouraging the client to limit fasting can help address the underlying issue of restricted food intake. Weight monitoring is crucial in assessing nutritional status, while monitoring behavior post-meals can provide insights into the client's relationship with food. Bulimia nervosa and binge eating disorder are not the most likely conditions based on the client's symptoms. Monitoring cardiac function with ECG and calcium level are not the primary parameters for assessing progress in anorexia nervosa.
A nurse is planning postoperative care for an adolescent following scoliosis repair with spinal instrumentation. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the head of the bed at a 30° angle.
- B. Offer sips of water due to having surgery.
- C. Log roll the adolescent every 2 hours.
- D. Assist the adolescent to ambulate 12 hours following surgery.
Correct Answer: C
Rationale: The correct answer is C: Log roll the adolescent every 2 hours. This is important to prevent pressure ulcers and maintain spinal alignment post-surgery. Log-rolling involves turning the patient as a unit to avoid twisting the spine. Maintaining the head of the bed at a 30° angle (choice A) is important for respiratory function but not specific to spinal surgery. Offering sips of water (choice B) is generally appropriate after surgery but not specific to spinal instrumentation. Assisting the adolescent to ambulate (choice D) should be done gradually and with caution, typically starting with sitting on the bedside first, rather than a fixed time frame like 12 hours post-surgery.
A nurse is preparing to administer immunizations to a 5-year-old child who is up to date with the current immunization schedule. Which of the following immunizations should the nurse plan to administer?
- A. Haemophilus influenzae type B
- B. Varicella
- C. Hepatitis B
- D. Diphtheria
Correct Answer: B
Rationale: The correct answer is B: Varicella. At the age of 5, children are due for their second dose of the Varicella vaccine according to the current immunization schedule. Varicella vaccine is given to protect against chickenpox. Haemophilus influenzae type B and Hepatitis B vaccines are typically administered at earlier ages. Diphtheria vaccine is usually given in combination with other vaccines and not as a standalone. In summary, Varicella is the correct choice as it aligns with the child's age and the recommended immunization schedule, while the other options are not due at this time.
A nurse is teaching a group of school-age children about healthy snack options. Which of the following snacks should the nurse include?
- A. Cheesecake
- B. Air-popped popcorn
- C. Milkshake made with whole milk
- D. Baked potato chips
Correct Answer: B
Rationale: The correct answer is B: Air-popped popcorn. It is a healthy snack option for school-age children because it is low in calories and high in fiber, making it a satisfying and nutritious choice. Popcorn is a whole grain snack that provides essential nutrients like fiber and antioxidants. It is a good alternative to sugary or high-fat snacks. Cheesecake (A) is high in sugar and saturated fat, not a healthy choice. Milkshake made with whole milk (C) is high in calories, sugar, and saturated fat. Baked potato chips (D) may be lower in fat than regular chips but are still high in calories and lack the fiber content of popcorn.
A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Place a throw rug over electrical cords.
- C. Mark the edges of the doorway to the house with tape.
- D. Ensure that area rugs have rubber backs.
Correct Answer: D
Rationale: The correct answer is D: Ensure that area rugs have rubber backs. This instruction is important because rugs with rubber backs are less likely to slip, reducing the risk of falls for the older adult post knee replacement surgery. Choice A is incorrect as wearing shoes at home can increase the risk of falls due to slippery surfaces. Choice B is incorrect as placing a throw rug over electrical cords can create a tripping hazard. Choice C is incorrect as marking the edges of the doorway with tape does not address the risk of tripping over rugs.