Nokea
A nurse is planning care for a 7-year-old who is hospitalized for a hernia repair. The nurse should assess the client for which of the following fears common in this age group?
- A. Separation from parents.
- B. Trying something new.
- C. Injury and pain.
- D. Opposite-sex relationships.
Correct Answer: C
Rationale: School-age children (7 years) commonly fear injury and pain, especially in medical settings, due to their growing awareness of bodily harm.
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A client with a history of chronic lymphocytic leukemia is admitted with fatigue. The nurse should monitor the client for which of the following?
- A. Anemia.
- B. Hyperkalemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Chronic lymphocytic leukemia can cause anemia due to bone marrow suppression, leading to fatigue.
A client with a history of osteoporosis is prescribed alendronate (Fosamax). The nurse should instruct the client to take the medication:
- A. At bedtime with a snack.
- B. First thing in the morning with water.
- C. With meals to enhance absorption.
- D. With milk to reduce stomach irritation.
Correct Answer: A
Rationale: Alendronate should be taken first thing in the morning with water, on an empty stomach, to maximize absorption and minimize esophageal irritation.
The nurse is working in a newborn nursery and caring for several neonates. Precautions that should be taken to prevent an infant abduction include which of the following?
- A. Notifying the hospital's security staff about anyone who appears unusual.
- B. Taking several neonates to their mothers at the same time.
- C. Placing the infant near the doorway of the mother's room.
- D. Contacting the hospital's security staff if an exit alarm is triggered.
Correct Answer: A,D
Rationale: Notifying security about suspicious individuals and responding to exit alarms are key to preventing abductions. Taking multiple neonates or placing them near doorways increases risk.
The nurse is assessing a client with suspected appendicitis. Which of the following findings would support this diagnosis?
- A. Pain at McBurney's point.
- B. Decreased bowel sounds.
- C. Bradycardia.
- D. Fever of 99°F.
Correct Answer: A, B
Rationale: Pain at McBurney's point and decreased bowel sounds are classic signs of appendicitis due to peritoneal irritation and intestinal obstruction.
Based on the fact that you family unit client is experiencing a situational crisis that has led to dysfunctional communication within the family unit, you have recommended that the entire nuclear family and members of the extended family who live in the family's home begin family therapy. The grandparents tell you that it is their grandson, rather than their son, who is addicted to prescription painkillers, is the cause of the problem; therefore, they do not have to participate in this group therapy. How should you respond to these grandparents?
- A. You should try to come to a few sessions at least because they may be very informative to you'.
- B. You are probably correct. This really is not your problem'.
- C. Despite the fact that it is your grandson's drug addiction, situations such as this affect all members of the family including grandparents who live in the home.'
- D. You should attend because the doctor has ordered family therapy for you as extended family members'.
Correct Answer: C
Rationale: Addiction affects the entire family system, including extended family members living in the home. Their participation in therapy can help address dysfunctional communication and support the family unit as a whole.