Nokea
An 18-month-old is admitted to the hospital with acute laryngotracheobronchitis. When assessing the respiratory status, the nurse should expect to find:
- A. Inspiratory stridor and harsh cough
- B. Strident cough and drooling
- C. Wheezing and intercostal retractions
- D. Expiratory wheezing and nonproductive cough
Correct Answer: A
Rationale: Acute laryngotracheobronchitis (croup) typically presents with inspiratory stridor and a harsh, barking cough due to subglottic airway inflammation.
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A client with a history of a bone marrow transplant is receiving immunosuppressive therapy. The nurse should monitor the client for:
- A. Infection
- B. Hypotension
- C. Hyperglycemia
- D. Hair loss
Correct Answer: A
Rationale: Immunosuppressive therapy post-bone marrow transplant increases infection risk due to suppressed immunity. Hypotension, hyperglycemia, and hair loss are less immediate concerns.
A 9-month-old infant was diagnosed with nonorganic failure to thrive. During her hospitalization, primary nurses were assigned to initiate all infant feedings. The infant's parents question why they cannot feed their own child. Which of the following responses would be most appropriate by the nurse?
- A. By assigning the same nurses to the child, the nurses can begin to learn the infant's cues and feeding behaviors.
- B. The same nurses will prevent parental fatigue and frustration.
- C. The same nurses will prevent infant fatigue and frustration.
- D. Primary nurses will ensure privacy.
Correct Answer: A
Rationale: Consistent primary care nurses can better interpret infant cues and note feeding behaviors, which is critical in managing nonorganic failure to thrive.
A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to be typical:
- A. Thready pulse
- B. Irregular pulse
- C. Tachycardia
- D. Bradycardia
Correct Answer: D
Rationale: Puerperal bradycardia with rates of 50-70 bpm commonly occurs during the first 6-10 days of the postpartal period. It may be related to decreased cardiac strain, decreased blood volume, contraction of the uterus, and increased stroke volume.
A client with a history of colorectal cancer is admitted with complaints of abdominal pain. The nurse should give priority to:
- A. Monitoring for obstruction
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Abdominal pain in colorectal cancer may indicate obstruction, a serious complication requiring immediate monitoring.
A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, 'The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart.' The nurse's best response is:
- A. I know you're feeling frightened right now, but I want you to know that I don't see anyone in the corner.'
- B. You'll probably see strange things for a while until the PCP wears off.'
- C. Try to sleep. When you wake up, the devil will be gone.'
- D. You're probably feeling guilty because you used illegal drugs tonight.'
Correct Answer: A
Rationale: The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and reinforcing reality.