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A nurse is discussing the concept of parallel play with parents of toddlers. Which statement should the nurse include to describe this type of play?
- A. Children play near other children but without significant interaction.
- B. Children playing together are strongly influenced by each other's choice of toy.
- C. The child primarily plays alone or with familiar people, such as parents.
- D. When playing in a group, one child will take on a follower role.
Correct Answer: A
Rationale: Parallel play is characteristic of toddlers, where children play alongside each other without significant interaction, focusing on their own activities.
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The nurse in a long-term care facility is talking with a client with multiple sclerosis who states, 'I want to live in my own home again.' Which of the following responses would be most appropriate for the nurse to make?
- A. Do you have family or friends who could live with you?
- B. I will refer you to a local home-health agency.
- C. How will you manage your care at home?
- D. Tell me more about your concerns.
Correct Answer: D
Rationale: Encouraging the client to express their concerns promotes client-centered care and helps the nurse understand the client's motivations and needs for returning home.
A client hospitalized with mania is racing wildly about the unit trying to organize the other clients into a game of Ping-Pong. The nurse should:
- A. Send the client to the recreation room for art therapy.
- B. Take the client outside for a walk.
- C. Allow the client to continue because his activities are goal directed.
- D. Suggest that the client do exercises to a video instead.
Correct Answer: B
Rationale: Taking the client for a walk redirects energy safely and reduces stimulation. Art therapy may not engage, continuing the activity risks escalation, and video exercises lack supervision.
An adult client is receiving oxygen at 6 L/min. The client asks the nurse why the oxygen is running through bubbling water. What should be included in the nurse's reply?
- A. The water cools the oxygen and makes it more comfortable.
- B. Oxygen is very drying to tissues; the water humidifies it.
- C. The water prevents fires when oxygen is in use.
- D. The water helps to prevent infections from developing in the tubing.
Correct Answer: B
Rationale: Bubbling water in oxygen delivery systems humidifies the oxygen, preventing mucosal drying. It doesn't cool oxygen, prevent fires, or reduce infections.
The family of a young man who has been declared brain dead following an accident tells the nurse that the doctors said their son would be a good organ donor. They ask the nurse if donating his organs would mean that they could not have a regular funeral. Which response by the nurse is most accurate?
- A. Donating organs does deface the body, so a closed casket is necessary.
- B. Ask the physician which organs would be donated.
- C. Organ donation involves a surgical incision but should not interfere with any type of funeral.
- D. Donating organs is a wonderful service to humanity.
Correct Answer: C
Rationale: Organ donation involves surgical incisions but allows for open-casket funerals with proper preparation, addressing the family's concern accurately.
The physician has recommended that an adult male be scheduled for a left heart catheterization. The client asks the nurse what a cardiac catheterization is for. What information should be included when responding to this client?
- A. During a left heart catheterization, the coronary arteries can be visualized.
- B. During a left heart catheterization, holes in the heart walls can be detected.
- C. During a left heart catheterization, blood flow to the lungs can be measured.
- D. During a left heart catheterization, oxygen levels in the chambers of the heart are measured.
Correct Answer: A
Rationale: Left heart catheterization visualizes coronary arteries to assess for blockages, aiding in diagnosing coronary artery disease.