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A nurse working in a pediatric clinic observes bruises on the body of a four year-old boy. The parents report the boy fell riding his bike. The bruises are located on his posterior chest wall and gluteal region. The nurse should:
- A. Suggest a script for counseling for the family to the doctor on duty.
- B. Recommend a warm bath for the boy to decrease healing time.
- C. Notify the case manager in the clinic about possible child abuse concerns.
- D. Recommend ROM to the patient's spine to decrease healing time.
Correct Answer: C
Rationale: The patient's safety should have the highest priority.
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The non-English-speaking hospitalized client begins to enter a room with the sign illustrated. Which intervention should the observing nurse implement?
- A. Inform the client's assigned nurse that the client is back in his or her room.
- B. Intercept the client and check the client's name band for a room number.
- C. Stop the client and ask for his or her name and the assigned room number.
- D. Ask the nearby UAP to help the client back into the room with the sign posted.
Correct Answer: B
Rationale: Intercepting and checking the name band ensures the client does not enter a radiation therapy room, accounting for the language barrier.
Which of these instructions should the nurse include when preparing a client for a radioactive iodine (I-131) uptake test and treatment for hyperthyroidism?
- A. Avoid taking aspirin for 3 days prior to the test.'
- B. You may eat a light breakfast on the morning of the test.'
- C. Expect to stay in the hospital for 24 hours after treatment.'
- D. In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation.'
Correct Answer: A
Rationale: In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after urination or defecation. The client's urine and saliva are radioactive for 24 hours after ingestion, and vomitus is radioactive for 6 to 8 hours.
When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend?
- A. Biofeedback
- B. Deep breathing
- C. Distraction
- D. Imagery
Correct Answer: B
Rationale: Deep breathing. Deep breathing is a reliable and valid method for reducing stress, and can be taught and reinforced in a short period pre-operatively.
A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is
- A. I must document and report any information.
- B. I can't make such a promise.
- C. That depends on what you tell me.
- D. I must report everything to the treatment team.
Correct Answer: B
Rationale: Secrets are inappropriate in therapeutic relationships and are counter productive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The nurse honors and helps clients to understand rights, limitations, and boundaries regarding confidentiality.
Signs of internal bleeding include all of the following except:
- A. painful or swollen extremities.
- B. a tender, rigid abdomen.
- C. vomiting bile.
- D. bruising.
Correct Answer: C
Rationale: Vomiting bile is usually not a sign of internal bleeding. Painful or swollen extremities, a tender, rigid abdomen, and bruising are indicative of internal bleeding.