Nokea
A nurse in the pediatric unit is preparing a 16-year-old for a surgical procedure and observes that the client has signed the informed consent for surgery. What should be the first action by the nurse?
- A. Cancel the procedure until a valid consent form is signed
- B. Determine if the client meets legal requirements to sign the consent form
- C. Locate the client's parent or guardian to sign the consent form
- D. Verify that the consent is properly witnessed and send the client to surgery
Correct Answer: B
Rationale: Minors typically cannot provide legal consent unless they are emancipated or meet specific legal criteria. The nurse must first determine if the 16-year-old is legally able to sign the consent.
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Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students?
- A. Scratching the head more than usual
- B. Flakes evident on a student's shoulders
- C. Oval pattern occipital hair loss
- D. Whitish oval specks sticking to the hair
Correct Answer: D
Rationale: Diagnosis of pediculosis capitis is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment can include application of a medicated shampoo with lindane for children over 2 years of age, and meticulous combing and removal of all nits.
The unlicensed assistive personnel notifies the charge nurse that the client is reporting feeling short of breath. What should the charge nurse do first?
- A. Activate a rapid response team
- B. Ask the unlicensed assistive personnel to take vital signs and report back
- C. Direct the client's primary nurse to examine the client
- D. Personally go and auscultate the client's lungs
Correct Answer: C
Rationale: Directing the primary nurse to assess the client ensures a timely, qualified evaluation of shortness of breath, a potentially serious symptom.
The nurse is teaching an adult who has a broken ankle that has been casted how to climb stairs. The nurse knows that the client understands how to climb up stairs when she does which of the following?
- A. While bearing weight on the unaffected leg, the client moves the crutches up to the next step followed by the affected leg and then the unaffected leg.
- B. While bearing weight on the unaffected leg, the client moves affected leg to the next step followed by the unaffected leg and the crutches.
- C. While bearing weight on crutches, the client moves the affected leg to the next step followed by the unaffected leg and the crutches.
- D. While bearing weight on crutches, the client moves the unaffected leg to the next step followed by the affected leg and the crutches.
Correct Answer: D
Rationale: To climb stairs, weight is borne on crutches, moving the unaffected leg first, then the affected leg and crutches, ensuring stability and safety using the stronger leg.
During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother?
- A. My child has lost 3 pounds in the last month.
- B. Urinary output seemed to be less over the past 2 days.
- C. All the pants have become tight around the waist.
- D. The child prefers some salty foods more than others.
Correct Answer: C
Rationale: All the pants have become tight around the waist. Increased abdominal girth is an early sign of Wilm's tumor.
An older adult is seen in clinic. During the assessment process, all of the following are expressed or noted. Which is of most immediate concern to the nurse?
- A. The client's daughter says that the client has become increasingly forgetful.
- B. The client has a productive cough.
- C. The client ambulates slowly.
- D. The client says, 'My arms aren't long enough for me to read the paper.'
Correct Answer: B
Rationale: A productive cough suggests a respiratory infection, potentially serious in an older adult, requiring immediate evaluation. Forgetfulness, slow ambulation, or presbyopia are less urgent.