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Nurse caring for 5 yo whose parents report she fears painful procedures, like shots. Which strategies should nurse use to try to help ease child's fear? (Select all that apply.)
- A. Invite child to assist with mealtime activities
- B. Cluster invasive procedures whenever possible
- C. Assign caregivers with whom the child is familiar
- D. Have parents bring in favorite toy from home
- E. Engage child in pretend play with toy medical kit
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
A: Inviting the child to assist with mealtime activities can help build trust and rapport, making the child more comfortable with the nurse.
D: Having parents bring in the child's favorite toy from home can provide comfort and distraction during procedures.
E: Engaging the child in pretend play with a toy medical kit can help familiarize the child with medical procedures in a non-threatening way.
Summary:
B: Clustering invasive procedures may not directly address the child's fear and can still be overwhelming.
C: Assigning caregivers familiar to the child may help in general care but may not directly address the fear of painful procedures.
F, G: No additional answer choices provided.
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Nurse talking with parents of 6 mo infant about gross motor development. Which gross motor skills are expected in next 3 mo? (Select all that apply.)
- A. Rolls from back to front
- B. Bears weight on legs
- C. Walks holding onto furniture
- D. Sits unsupported
- E. Sits down from standing position
Correct Answer: A,B,D
Rationale: The correct answers are A, B, and D. In the next 3 months, the infant is expected to roll from back to front (A), bear weight on legs (B), and sit unsupported (D). Rolling develops around 4-6 months, weight-bearing on legs around 6-9 months, and sitting unsupported around 6-8 months. Choice C, walking holding onto furniture, is more characteristic of the 9-12 month age range. Choice E, sitting down from a standing position, typically occurs after the infant has mastered standing independently, which is beyond the 9-month mark.
Nurse is caring for many clients during mass casualty event. Which client is highest priority?
- A. Client with crush injuries to chest/abdomen & expected to die
- B. Client with 4-inch laceration to head
- C. Client with partial & full-thickness burns to face
- D. neck
- E. chest
Correct Answer: C
Rationale: The correct answer is C: Client with partial & full-thickness burns to face. This client is the highest priority due to airway compromise risk from facial burns. Airway is a top priority in mass casualty events to prevent respiratory distress or failure. Crush injuries (A) may be severe but not immediately life-threatening. Laceration (B) to head can be managed with proper wound care. Clients with neck (D) or chest (E) injuries may have potential serious complications, but airway takes precedence in this scenario.
When nurse is observing client drawing up & mixing insulin injections, which best demonstrates psychomotor learning has taken place?
- A. Client able to discuss appropriate technique
- B. Client able to demonstrate appropriate technique
- C. Client states he understands
- D. Client is able to write steps on piece of paper
Correct Answer: B
Rationale: The correct answer is B because demonstrating the appropriate technique shows psychomotor learning has taken place. This means the client has acquired the physical skills needed to draw up and mix insulin injections. Discussing technique (A) only shows verbal understanding, not necessarily physical ability. Stating understanding (C) shows cognitive learning, not physical skill. Writing steps on paper (D) demonstrates knowledge but not practical application.
Nurse is admitting older adult who lost 4.5 kg since last admission 6 months ago. Which questions should nurse ask to investigate source of weight loss? (Select all that apply.)
- A. Do you eat alone or with someone?
- B. Do you watch TV while eating your meals?
- C. Have you started any new meds in past 6 months?
- D. What foods have you eaten in past 24 hours?
- E. Are you on a fixed income?
Correct Answer: A,C,D,E
Rationale: The correct answers are A, C, D, and E.
A: Asking if the person eats alone or with someone helps to assess social factors influencing eating habits, such as loneliness or lack of social interaction affecting appetite.
C: Inquiring about new medications can reveal potential side effects like appetite changes, nausea, or malabsorption leading to weight loss.
D: Knowing the foods consumed in the past 24 hours helps identify dietary patterns that may contribute to weight loss, such as poor nutrition or reduced intake.
E: Asking about a fixed income can uncover financial constraints affecting food choices and access to nutritious meals, potentially leading to weight loss.
Summary:
B: Watching TV while eating is not directly related to weight loss causes.
F and G: Not provided in the question, so no basis to consider them as relevant questions for investigating weight loss.
Nurse wearing sterile gloves in prep for performing sterile procedure. Which of following objects may nurse touch without breaching sterile technique?
- A. Bottle containing sterile solution
- B. Edge of sterile drape at base of field
- C. Inner wrapping of an item on sterile field
- D. Irrigation syringe on sterile field
- E. 1 gloved hand with the other gloved hand
Correct Answer: C,D,E
Rationale: The correct choices are C, D, and E. The nurse can touch the inner wrapping of an item on the sterile field because it is considered sterile. The nurse can touch the irrigation syringe on the sterile field as long as it is also considered sterile and part of the field. The nurse can also touch one gloved hand with the other gloved hand, as the gloves are considered sterile. Choices A and B are incorrect because touching the bottle or the edge of the drape would breach sterile technique.