Nokea
A nurse is preparing to assess a 3-year-old child. What communication technique should the nurse use for this child?
- A. Focus communication on child.
- B. Explain experiences of others to child.
- C. Use easy analogies when possible.
- D. Assure child that communication is private.
Correct Answer: A
Rationale: When assessing a young child, it is important for the nurse to focus communication on the child by using simple language, asking direct questions, and using play-based approaches to facilitate communication. By engaging the child directly and adapting communication techniques to their developmental level, the nurse can establish rapport, gain the child's trust, and obtain accurate information during the assessment process. This approach helps create a positive and supportive environment for the child, making them feel comfortable and understood.
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Mr. and Mrs. Smith's child has hemophilia; which of the following actions would you instruct them to avoid?
- A. Immobilizing the joint
- B. Lowering the injured area
- C. Applying cold to the area
- D. Applying pressure
Correct Answer: C
Rationale: Hemophilia is a condition where the blood fails to clot properly. Applying cold to the area can cause vasoconstriction (narrowing of blood vessels) which may slow down the blood flow and exacerbate the bleeding in individuals with hemophilia. Therefore, instructing Mr. and Mrs. Smith to avoid applying cold to the area of injury is crucial in order to prevent further complications.
Which is a major complication in a child with chronic renal failure?
- A. Hypokalemia
- B. Metabolic alkalosis
- C. Water and sodium retention
- D. Excessive excretion of blood urea nitrogen
Correct Answer: C
Rationale: A major complication in a child with chronic renal failure is water and sodium retention, leading to fluid overload and hypertension. Because the kidneys are not functioning properly, they are unable to regulate fluid and sodium levels in the body effectively. This can result in edema, increased blood pressure, and potential heart complications. Monitoring and managing fluid and sodium intake are essential in managing this complication in children with chronic renal failure.
When teaching a preoperative older patient, which of the following is a technique to improve learning?
- A. Sit in front of window in bright sunlight.
- B. Speak in high tone.
- C. Use small, white-on-black printed
- D. Eliminate background noise. materials.
Correct Answer: D
Rationale: Eliminating background noise is a beneficial technique when teaching an older patient preoperatively. Older individuals may have age-related hearing impairments, making it difficult for them to focus and understand information in the presence of background noise. By minimizing distractions and background noise, the older patient can better concentrate on the information being taught and improve their learning experience.
A client is admitted to the ICU, which laboratory result must be reported immediately to the physician?
- A. Hematocrit 48%
- B. paCO2 38 mm Hg
- C. platelets 18,000
- D. WBC count 8000
Correct Answer: C
Rationale: A platelet count of 18,000 is significantly low, indicating a condition known as thrombocytopenia, which can lead to a risk of bleeding. In a critical care setting like the ICU, low platelet counts need to be addressed urgently to prevent serious complications such as hemorrhage. This result must be reported immediately to the physician so that appropriate interventions, such as transfusion of platelets, can be initiated promptly to manage the patient's condition effectively. Hematocrit, paCO2, and WBC count may also be important parameters to monitor in an ICU patient, but the critically low platelet count poses the most immediate threat to the patient's well-being and requires urgent attention.
A client with colon cancer requires a permanent colostomy because of the tumor location. After surgery, the client must learn how to irrigate the colostomy. When irrigating, how far into the stoma should the client insert the lubricated catheter?
- A. 0.25" to 0.5"
- B. 2" to 4"
- C. 1" to 1.5"
- D. 5" to 7"
Correct Answer: C
Rationale: When irrigating a colostomy, the client should insert the lubricated catheter approximately 1 to 1.5 inches (2.5 to 4 cm) into the stoma. This depth ensures that the catheter reaches the optimal level within the colon to effectively irrigate and cleanse the colon contents. Inserting the catheter too shallow may not reach the colon, while inserting it too deep can cause discomfort or injury to the lining of the colon. It is important for the client to be educated on the correct technique and depth for colostomy irrigation to maintain bowel regularity and health.