Nokea
During the admission procedure of a school age child, the child states, 'I'm going to have an operation.' Which response is best for the nurse to provide to this child?
- A. Tell me what an operation is.'
- B. We're going to do everything we can to take very good care of you.'
- C. I'm glad your mother told you why you were coming to the hospital.'
- D. Are you scared?'
Correct Answer: A
Rationale: Asking the child to explain their understanding assesses knowledge, addresses misconceptions, and supports age-appropriate communication.
You may also like to solve these questions
The nurse is providing preconception counseling. Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?
- A. Folic acid.
- B. Iron.
- C. Vitamin D.
- D. Calcium.
Correct Answer: A
Rationale: Folic acid (400-800 mcg daily) prevents neural tube defects like anencephaly by supporting neural tube closure.
The nurse is caring for a child with a unilateral long-leg cast applied for the correction of club foot. Which action is most important for the nurse to perform?
- A. Palpate femoral pulses.
- B. Compare temperature of both legs.
- C. Monitor capillary refill of the toes.
- D. Examine for spontaneous movement.
Correct Answer: C
Rationale: Monitoring capillary refill ensures adequate circulation in the casted limb, detecting complications like compartment syndrome.
History and Physical
Nurses' Notes
Flow Sheet
Laboratory Results
38-year-old primiparous client is seen in the outpatient obstetric office 2 weeks postpartum after a spontaneous vaginal birth of a full-term infant after rupture of membranes for 16 hours. The client was discharged on day 2, exclusively breastfeeding.
For each assessment finding, click to indicate whether findings from this client's assessment are generally associated with mastitis, endometritis, or could be a sign of both conditions.
- A. Pulse of 105 beats/minute - Both mastitis and endometritis
- B. Feeling chilled, achy, and fatigued - Both mastitis and endometritis
- C. Baby fed pumped breast milk - Mastitis
- D. Pain rating of 4 on a 0 to 10 scale - Mastitis
- E. Foul-smelling lochia rubra at 2 weeks postpartum - Endometritis
- F. Temperature of 101.2° F (38.4°C) - Both mastitis and endometritis
Correct Answer: B,D
Rationale: Tachycardia, chills, aches, fatigue, and fever are systemic signs of infection in both mastitis and endometritis. Feeding pumped milk and localized breast pain suggest mastitis due to milk stasis. Foul-smelling lochia is specific to endometritis, indicating uterine infection.
The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. Which priority issue should the nurse address to ensure the newborn's survival?
- A. Heat loss.
- B. Fluid balance.
- C. Bleeding tendencies.
- D. Hypoglycemia.
Correct Answer: A
Rationale: Preventing heat loss avoids cold stress, which can lead to respiratory distress and metabolic issues, critical for newborn survival.
A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, 'I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?' Which information should the nurse provide?
- A. Describe genetic testing protocols.
- B. Sign up for group therapy sessions.
- C. Start a prenatal care plan as soon as possible.
- D. Discontinue the methadone right away.
Correct Answer: C
Rationale: Early prenatal care monitors methadone effects, fetal development, and complications like neonatal abstinence syndrome, ensuring a healthy pregnancy.