Nokea
An adolescent male client scheduled for an emergency appendectomy is to be transferred directly from the emergency room to the operating room. Which of the following statements by the client should the nurse interpret as most significant?
- A. I'm scared about the surgery.
- B. I need to call my parents first.
- C. My pain is getting worse.
- D. I don't want to have a scar.
Correct Answer: C
Rationale: Worsening pain may indicate perforation, requiring urgent attention.
You may also like to solve these questions
The nurse has identified a priority nursing diagnosis of Anxiety related to surgery for a 4-yearold preparing for a tonsillectomy. The nurse should tell the child:
- A. You won't have so many sore throats after your tonsils are removed.
- B. The doctor will put you to sleep so you don't feel anything.
- C. Show me how to give the doll an I.V.
- D. When it is done you will get to see your mommy and get a Popsicle.
Correct Answer: D
Rationale: When preparing a child for a procedure the nurse should use neutral words, focus on sensory experiences, and emphasize the positive aspects at the end. Being reunited with parents and having an ice pop would be considered pleasurable events. Children this age fear bodily harm. To reduce anxiety, avoid the word 'removed' to describe what is being done to the tonsils. Using the terms 'put to sleep' and 'I.V.' may be threatening. Additionally, directing a play experience to focus on I.V. insertion may be counterproductive as the child may have little recollection of this aspect of the procedure.
The nurse is assessing a child with celiac disease. Which symptom should the nurse expect?
- A. Constipation.
- B. Abdominal distension.
- C. Fever.
- D. Joint pain.
Correct Answer: B
Rationale: Abdominal distension is a common symptom of celiac disease due to malabsorption and gas. Diarrhea is more typical than constipation, and fever or joint pain are less specific.
The nurse is admitting a child who has been diagnosed with bacterial meningitis to the pediatric unit. The nurse should implement which type of isolation?
- A. Standard precautions.
- B. Contact precautions.
- C. Airborne precautions.
- D. Droplet precautions.
Correct Answer: D
Rationale: Bacterial meningitis, such as meningococcal, requires droplet precautions due to transmission via respiratory secretions.
A mother states that she thinks her 9-month-old 'is developing slowly.' When assessing the infant's development, the nurse is also concerned because the infant should be demonstrating which of the following characteristics?
- A. Vocalizing single syllables.
- B. Standing alone.
- C. Building a tower of two cubes.
- D. Drinking from a cup with little spilling.
Correct Answer: C
Rationale: Building a tower of two cubes is expected by 9 months; failure to do so suggests developmental delay.
The nurse teaches the mother of a young child with Duchenne's muscular dystrophy about the disease and its management. Which of the following statements by the mother indicates successful teaching?
- A. My son will probably be unable to walk independently by the time he is 9 to 11 years old.'
- B. Muscle relaxants are effective for some children; I hope they can help my son.'
- C. When my son is a little older, he can have surgery to improve his ability to walk.'
- D. I need to help my son be as active as possible to prevent progression of the disease.'
Correct Answer: A
Rationale: Children with Duchenne's muscular dystrophy typically lose the ability to walk independently by ages 9 to 11 due to progressive muscle weakness.