Nokea
An 18 month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin, and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of
- A. Septicemia
- B. Dehydration
- C. Hypokalemia
- D. Hypercalcemia
Correct Answer: B
Rationale: Dehydration. These symptoms are consistent with dehydration, requiring further assessment for fluid status.
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The nurse is reinforcing health promotion education to the parents of a toddler. Which statement by a parent requires the nurse to clarify teaching?
- A. I will offer my child options rather than asking yes or no questions
- B. I will wait at least 15 minutes after a play period to offer a meal to my child
- C. If my child is having a tantrum, I will have them sit in a quiet area for a short time-out
- D. If my child refuses a meal, I will have them stay at the table until they eat half the food.
Correct Answer: B
Rationale: Waiting 15 minutes after play to offer a meal is unnecessary and may disrupt healthy eating habits. Offering options and using time-outs are age-appropriate parenting strategies.
The nurse is caring for assigned clients. The nurse should first check the client with
- A. sickle cell disease who has new onset pain rated as 9 on a scale of 0-10
- B. pneumonia who has a temperature of 100.6°F (38.1°C) and is receiving IV antibiotics
- C. Graves’ disease who has a heart rate of 110/min and a blood pressure of 122/85 mm Hg
- D. diabetes mellitus who has an elevated serum glucose level and is requesting insulin lispro prior to a meal
Correct Answer: A
Rationale: Severe pain (9/10) in sickle cell disease indicates a possible vaso-occlusive crisis, a medical emergency requiring immediate assessment. Fever, tachycardia, and hyperglycemia are less urgent.
When interviewing the parents of a child with asthma, it is most important to assess the child's environment for what factor?
- A. Household pets
- B. New furniture
- C. Lead based paint
- D. Plants such as cactus
Correct Answer: A
Rationale: Animal dander is a very common allergen affecting persons with asthma. Other triggers may include pollens, carpeting and household dust.
The nurse is caring for a client who reported having thoughts of self-injury yesterday. Which of the following statements by the client should the nurse recognize as risk factors for suicide? Select all that apply.
- A. I am currently unemployed and looking for a job
- B. I have been married for five years with three children
- C. I have multiple firearms at home stored in a safe
- D. I have been about a year since I last overdosed
- E. I attend weekly religious activities with my family
- F. Sometimes I experience feelings of hopelessness
Correct Answer: A,C,D,F
Rationale: Unemployment, access to firearms, prior overdose, and hopelessness are established suicide risk factors. Marriage with children and religious activities are protective factors.
What nursing action is essential when oxygen is ordered for a client who is living at home?
- A. Assist the client and family in checking all electrical appliances in the vicinity for frayed cords.
- B. Encourage the client and family to purchase fire extinguishers.
- C. Remove electrical devices from the room where oxygen is in use.
- D. Encourage the client and family to carpet the client's room.
Correct Answer: A
Rationale: Checking for frayed cords reduces fire risk, as oxygen supports combustion. Extinguishers are secondary, removing devices is impractical, and carpeting increases static sparks.