Nokea
An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. The nurse should advise the mother to do which of the following?
- A. Notify the physician immediately to adjust the treatment plan.
- B. Confine the infant to one room in the apartment.
- C. Keep the infant in the splint at night, removing it during the day.
- D. Remove any unsafe items from the area in which the infant is mobile.
Correct Answer: D
Rationale: Removing unsafe items ensures the infant's safety while mobile in a splint, preventing further injury. The other options are unnecessary or impractical.
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During a clinic visit for a postpartum examination, the mother of a 2-week-old infant tearfully tells the nurse she feels very tired and thinks she is not a good mother to her baby. Which statement by the nurse would be best?
- A. The hormonal changes your body is experiencing are causing you to feel this way.'
- B. Most new mothers feel the same way that you do. I hear that a lot from others.'
- C. You need to have your husband and family help you so that you can get some rest.'
- D. I'm concerned about what you are experiencing. Tell me more about what you are thinking and feeling.'
Correct Answer: D
Rationale: Acknowledging the mother's feelings and encouraging her to elaborate promotes therapeutic communication and helps assess for postpartum depression or other concerns. Attributing feelings solely to hormones, normalizing without exploration, or suggesting family help without assessment may miss underlying issues.
A client with bipolar disorder is admitted during a depressive episode. Which intervention should the nurse prioritize?
- A. Encourage group therapy participation
- B. Monitor for suicidal ideation
- C. Administer a mood stabilizer
- D. Provide a high-calorie diet
Correct Answer: B
Rationale: During a depressive episode, monitoring for suicidal ideation is the priority to ensure client safety, given the high risk of suicide in bipolar depression.
A client with a history of osteoarthritis is prescribed ibuprofen. The nurse should instruct the client to take the medication:
- A. On an empty stomach to enhance absorption.
- B. With food to reduce gastrointestinal irritation.
- C. At bedtime to promote sleep.
- D. With a diuretic to reduce swelling.
Correct Answer: B
Rationale: Ibuprofen should be taken with food to minimize gastrointestinal irritation and reduce the risk of ulcers.
A client has been taking benzonatate as prescribed. The nurse should tell the client this medication performs which action?
- A. Increases comfort level
- B. Decreases anxiety level
- C. Calms the persistent cough
- D. Takes away nausea and vomiting
Correct Answer: C
Rationale: Benzonatate is a locally acting antitussive. Its effectiveness is measured by the degree to which it decreases the intensity and frequency of cough, without eliminating the cough reflex. The remaining options are not intended effects of this medication.
Which of the following should first alert the nurse that a child is hemorrhaging after a tonsillectomy?
- A. Mouth breathing.
- B. Frequent swallowing.
- C. Requests for a drink.
- D. Increased pulse rate.
Correct Answer: B
Rationale: Frequent swallowing is the earliest sign of post-tonsillectomy hemorrhage, as the child swallows blood from the surgical site. Increased pulse rate may occur later.