Nokea
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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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 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.
The nurse is caring for a 4-year-old who was hospitalized with influenza. Which nursing action would be most effective to maintain psychosocial integrity?
- A. Encouraging use of puzzles for play
- B. Offering the child stacking blocks for diversion
- C. Providing crayons to draw noses on facemasks
- D. Suggesting that playmates visit the child
Correct Answer: C
Rationale: Drawing on facemasks is an age-appropriate, creative activity that promotes self-expression and reduces fear associated with medical equipment, supporting psychosocial integrity.
The nurse is walking through a crowded waiting room when the respiratory therapist approaches the nurse and asks, 'How is the client in room 312?' Which of the following responses would be most appropriate for the nurse to make?
- A. I will document my most recent assessment in the client's medical record for your review.
- B. Additional medications were prescribed to help improve the client's respiratory status.
- C. The client was doing much better when I last checked during hourly rounds.
- D. We need to move away from this area to discuss the client's status.
Correct Answer: D
Rationale: Discussing client information in a crowded area risks breaching confidentiality. Moving to a private area ensures compliance with HIPAA and protects client privacy.
A client with severe hypertension is receiving Capoten (captopril). The nurse should instruct the client to report which of the following to the doctor?
- A. Coughing
- B. Drowsiness
- C. Frequent urination
- D. Hunger
Correct Answer: A
Rationale: A persistent cough is a common side effect of ACE inhibitors like captopril, potentially requiring a change in medication.