Nokea
A toddler with suspected conjunctivitis is crying and refuses to sit still during the eye examination. Which is the most appropriate statement for the nurse to make to the child?
- A. Would you like to see my flashlight?
- B. Don't be scared, the light won't hurt you.
- C. If you will sit still, the exam will be over soon.
- D. I know you are upset. We can do this exam later.
Correct Answer: A
Rationale: Engaging the toddler by offering to show the flashlight reduces fear and encourages cooperation, suitable for this developmental stage. Other options either dismiss feelings, demand compliance, or delay the necessary exam inappropriately.
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The nurse is reviewing home care instructions with a client who has been diagnosed with type 1 diabetes mellitus and has a history of diabetic ketoacidosis (DKA). The client's spouse is present when the instructions are given. Which statement by the spouse indicates that further teaching is necessary?
- A. If he is vomiting, I shouldn't give him any insulin.
- B. I should bring him to the doctor if he develops a fever.
- C. If our grandchildren are sick, they probably shouldn't come to visit.
- D. I should call the doctor if he has nausea or abdominal pain lasting for more than 1 or 2 days.
Correct Answer: A
Rationale: Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus that develops when a severe insulin deficiency occurs. Infection and the stopping of insulin are precipitating factors for DKA. Nausea and abdominal pain that last more than 1 or 2 days need to be reported to the primary health care provider because these signs/symptoms may be indicative of DKA. Withholding insulin during vomiting can exacerbate DKA and is incorrect.
The nurse is talking to a 67-year-old client who has just retired from the job he's had since age 17-the only job he's ever had. The nurse understands that the client is in which of Erikson's stages?
- A. intimacy versus isolation
- B. ego integrity versus despair
- C. identity versus role confusion
- D. generativity versus stagnation
Correct Answer: B
Rationale: A 67-year-old retiree is in Erikson's ego integrity versus despair stage, reflecting on life's accomplishments.
The nurse is teaching umbilical cord care to a new mother. What information should the nurse provide to the mother related to cord care?
- A. Alcohol is the only agent to use to clean the cord.
- B. Cord care is done only at birth to control bleeding.
- C. It takes at least 21 days for the cord to dry up and fall off.
- D. The process of keeping the cord clean and dry will decrease bacterial growth.
Correct Answer: D
Rationale: The cord should be kept clean and dry to decrease bacterial growth. It should be cleansed two to three times a day with a prescribed agent. Usually the cord is cleansed with soap and water around base of the cord where it joins the skin. The primary health care provider is notified of any odor, discharge, or skin inflammation. The diaper should not cover the cord because a wet or soiled diaper will slow or prevent drying of the cord and foster infection. Cord care is required until the cord dries up and falls off between 7 and 14 days after birth.
A first-time parent is discussing developmental milestones with a nurse. The nurse tells the client she can reasonably expect her child to achieve which of the following by the time the child is 2 years old?
- A. is left-hand dominant
- B. clings to caregivers in new situations
- C. walks with assistance of another
- D. says several single words
Correct Answer: D
Rationale: By age 2, children typically say several single words. Hand dominance emerges later, clinging is earlier, and walking is independent by 2.
The nurse teaches a preoperative client about the nasogastric (NG) tube that will be inserted in preparation for surgery. The nurse determines that the client understands when the tube will be removed during the postoperative period based on which statement by the client?
- A. When my doctor says so.
- B. When I can tolerate food without vomiting.
- C. When my gastrointestinal (GI) system is healed.
- D. When my bowels begin to function again and I begin to pass gas.
Correct Answer: D
Rationale: NG tubes are discontinued when normal function returns to the GI tract. Although the surgeon determines when the NG tube will be removed, 'When my doctor says so' does not determine the effectiveness of teaching. Food would not be administered unless bowel function returns. The tube will be removed well before GI healing occurs.