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A nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group?
- A. Believes the death is punishment for bad behavior
- B. Understands that everyone dies eventually
- C. Recognizes the parent will never wake up
- D. Expresses curiosity about the funeral service
Correct Answer: A
Rationale: Preschoolers often view death as punishment due to magical thinking.
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A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?
- A. Place the shoulder harnesses at the level of the infant's shoulders.
- B. Put a small cushion under the newborn's head for support.
- C. Position the car seat at a 90-degree angle.
- D. Keep the airbag on if the car seat is in the front seat.
Correct Answer: A
Rationale: Shoulder harnesses at shoulder level ensure proper restraint fit.
A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?
- A. Diminished pulses on the affected extremity
- B. Ecchymosis on the inner left thigh
- C. Client report of muscle spasms of the left leg
- D. One fingerbreadth of space between the cast and the skin
Correct Answer: A
Rationale: Diminished pulses suggest vascular compromise, a priority concern.
A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following the procedure?
- A. Sleep apnea
- B. Paresthesias
- C. Disorientation
- D. Tonic-clonic seizures
Correct Answer: C
Rationale: Disorientation is common shortly after ECT.
A nurse is reinforcing teaching about the side effects of metoprolol. Which of the following client statements indicates an understanding of the teaching?
- A. I need to be careful when standing up from bed.
- B. I should limit my intake of leafy green vegetables.
- C. I should expect some weight loss.
- D. I may experience loss of taste.
Correct Answer: A
Rationale: Metoprolol can cause orthostatic hypotension, requiring caution when standing.
A nurse is receiving a telephone prescription from a client's provider. Which of the following actions should the nurse take? (Select all that apply)
- A. Instruct another nurse to record the prescription in the medical record.
- B. Ask the provider to spell out the name of the medication.
- C. Withhold the medication until the provider signs the prescription.
- D. Record the date and time of the telephone prescription.
- E. Request that the provider confirm the read-back of the prescription.
Correct Answer: B,D,E
Rationale: Spelling the medication, recording date/time, and confirming read-back ensure accuracy and safety.