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A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following activities should the nurse expect the child to participate?
- A. Using scissors to cut out paper shapes
- B. Playing with a large plastic truck
- C. Looking at alphabet flash cards
- D. Watching a cartoon in the activity room
Correct Answer: D
Rationale: The correct answer is D: Watching a cartoon in the activity room. Toddlers with acute lymphocytic leukemia are often immunocompromised, making them susceptible to infections. Therefore, activities that involve potential injury or exposure to germs, such as using scissors (choice A) or playing with toys that cannot be easily cleaned (choice B) should be avoided. Looking at alphabet flash cards (choice C) may be mentally stimulating but does not address the safety concerns. Watching a cartoon in the activity room (choice D) is a safe and enjoyable activity that can help keep the child entertained without posing a risk of injury or infection.
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A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take.
- A. Apply pressure to the lacrimal punctum.
- B. Place the child in a sitting position.
- C. Instill the drops of medication.
- D. Pull the lower eyelid downward.
- E. Ask the child to look upward.
Correct Answer: B,C,D,E
Rationale: The correct order is B, C, D, E. First, placing the child in a sitting position ensures safety and easy access to the eyes. Next, instilling the drops of medication into the conjunctival sac is essential for proper administration. Then, pulling the lower eyelid downward helps to create a pocket for the drops to be placed. Finally, asking the child to look upward aids in the proper distribution of the medication. Choice A is incorrect as applying pressure to the lacrimal punctum is not necessary for administering eye drops. Choices F and G are not applicable in this scenario.
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 on a pediatric unit is caring for four children. The nurse should use droplet precautions for which of the following children?
- A. A school-age child who has viral conjunctivitis
- B. A preschool-age child who has pediculosis capitis
- C. A toddler who has seasonal influenza
- D. An adolescent who has hepatitis A
Correct Answer: C
Rationale: The correct answer is C: A toddler who has seasonal influenza. Droplet precautions are required for diseases transmitted via respiratory droplets, such as influenza. Seasonal influenza is highly contagious through respiratory secretions, making it crucial to prevent transmission. The other choices do not require droplet precautions: A - viral conjunctivitis is spread through direct contact with eye secretions, B - pediculosis capitis (head lice) is spread through direct head-to-head contact, and D - hepatitis A is primarily spread through the fecal-oral route. Therefore, C is the correct choice for droplet precautions.
A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?
- A. Perform the procedure prior to meals.
- B. Hold hand flat to perform percussions on the child.
- C. Administer a bronchodilator after the procedure.
- D. Perform the procedure twice each day.
Correct Answer: A
Rationale: The correct answer is A: Perform the procedure prior to meals. Postural drainage helps clear mucus from the lungs. Performing it before meals prevents aspiration since the child's stomach will be empty. This timing also maximizes the effectiveness of postural drainage by clearing the airways before meals, which can help improve breathing.
B: Holding hand flat for percussions is incorrect as cupped hands are used to provide effective percussions.
C: Administering a bronchodilator after the procedure does not relate to the timing of postural drainage.
D: Performing the procedure twice each day is not specific to the timing of postural drainage.
A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
- A. Assign the child to a negative air pressure room.
- B. Administer aspirin to the child for fever.
- C. Use droplet precautions when caring for the child.
- D. Assess the child for Koplik spots.
Correct Answer: A
Rationale: The correct answer is A: Assign the child to a negative air pressure room. Varicella, commonly known as chickenpox, is highly contagious and spreads through respiratory droplets. Placing the child in a negative air pressure room helps prevent the spread of the virus to others by containing the infectious particles within the room. This isolation measure is crucial in protecting both the child and other patients.
Choice B is incorrect because aspirin should not be administered to children with varicella due to the risk of Reye's syndrome. Choice C is incorrect as droplet precautions are not necessary for varicella, which primarily spreads through airborne respiratory droplets. Choice D is incorrect as Koplik spots are associated with measles, not varicella.