Nokea
A nurse is assessing a school-age child who is receiving morphine. For which of the following adverse effects should the nurse monitor?
- A. Hypertension
- B. Bradypnea
- C. Stevens-Johnson syndrome
- D. Prolonged wound healing
Correct Answer: B
Rationale: The correct answer is B: Bradypnea. Morphine is an opioid that can cause respiratory depression, leading to bradypnea (slow breathing). The nurse should monitor the child's respiratory rate regularly as a safety precaution. Hypertension (A), Stevens-Johnson syndrome (C), and prolonged wound healing (D) are not typically associated with morphine use in school-age children. Monitoring for these adverse effects would not be a priority in this situation.
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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 to prevent slips and falls, as rubber-backed rugs provide better traction on smooth surfaces, reducing the risk of accidents. Placing throw rugs over electrical cords (B) can cause tripping hazards. Marking the edges of the doorway with tape (C) may not be effective and can be unsightly. Encouraging the client to avoid wearing shoes at home (A) may not directly impact safety. Overall, ensuring area rugs have rubber backs (D) is the most practical and effective approach to enhancing home safety for a postoperative older adult.
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 providing teaching to the guardian of an 11-month-old infant who has acute diarrhea. Which of the following food items should the nurse instruct the parent to provide to the infant?
- A. Children's tea
- B. Oral rehydration solution
- C. White grape juice
- D. Applesauce
Correct Answer: B
Rationale: The correct answer is B: Oral rehydration solution. This is the most appropriate choice because infants with acute diarrhea are at risk of dehydration due to fluid loss. Oral rehydration solution helps replace lost fluids and electrolytes, preventing dehydration. Children's tea (A) and white grape juice (C) are not recommended as they can worsen diarrhea due to their high sugar content. Applesauce (D) is also not suitable as it may be difficult for the infant to digest during diarrhea. It's important to prioritize rehydration in infants with diarrhea to prevent complications.
A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first?
- A. Notify the client's support person.
- B. Teach the client relaxation techniques.
- C. Help the client identify personal strengths.
- D. Confirm the client's perception of the event.
Correct Answer: D
Rationale: The correct answer is D: Confirm the client's perception of the event. This is the first step because it helps the nurse understand the client's perspective, emotions, and triggers, which are crucial in crisis intervention. By confirming the client's perception, the nurse can establish rapport, validate the client's feelings, and assess the severity of the crisis. This information guides the nurse in developing an appropriate care plan and intervention strategies.
Choice A (Notify the client's support person) may be important but not the first step in crisis intervention. Choice B (Teach the client relaxation techniques) and C (Help the client identify personal strengths) are valuable interventions but should come after assessing the client's perception.
A nurse is providing teaching to the parent of a 10-month-old infant who is having difficulty eating. The parent is feeding the infant goat milk. Which of the following instructions should the nurse include?
- A. Continue breastfeeding.
- B. Warm the goat milk before feeding.
- C. Switch to soy milk.
- D. Add honey to the milk to improve taste.
Correct Answer: A
Rationale: The correct answer is A: Continue breastfeeding. Breast milk is the ideal source of nutrition for infants under one year old. It provides essential nutrients and antibodies that support the infant's growth and immune system. Goat milk is not recommended as a substitute for breast milk or infant formula due to its different nutrient composition. Continuing breastfeeding will ensure the infant receives the necessary nutrients for proper development. Choice B is incorrect as warming the goat milk does not address the issue of inadequate nutrition. Choice C suggests switching to soy milk, which is also not recommended for infants under one year old due to potential allergenicity. Choice D is incorrect and unsafe as honey should not be given to infants under one year old due to the risk of botulism.