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Nurse on peds unit is caring for adolescent with multiple fractures. Which interventions are appropriate for client? (Select all that apply.)
- A. Suggest his parents room in with him
- B. Provide a TV & DVDs for him to watch
- C. Limit visitors to immediate family
- D. Devise a regular schedule for inpatient routines
- E. Allow him to perform his own morning care
Correct Answer: B,E
Rationale: The correct choices are B and E. Providing a TV & DVDs and allowing the adolescent to perform his own morning care are appropriate interventions for the client's care. Offering entertainment can help with psychological well-being. Allowing independence in self-care promotes autonomy and self-esteem. Choice A may not be appropriate for an adolescent seeking independence. Choice C may restrict emotional support from close friends. Choice D is important but not the most crucial in this scenario.
You may also like to solve these questions
A nurse is assessing body alignment. What is the nurse monitoring?
- A. The relationship of one body part to another while in different positions
- B. The coordinated efforts of the musculoskeletal and nervous systems
- C. The force that occurs in a direction to oppose movement
- D. The inability to move about freely
Correct Answer: A
Rationale: The correct answer is A. The nurse is monitoring the relationship of one body part to another while in different positions to ensure proper alignment. This is crucial for preventing musculoskeletal issues. Choice B refers to coordination, not body alignment. Choice C refers to resistance, not alignment. Choice D refers to immobility, not alignment.
Nurse reviewing CDC's immunization recommendations with parents of 2 preschoolers. Which recommendations should nurse include in this discussion? (Select all that apply.)
- A. Haemophilus influenzae type b
- B. Varicella
- C. Polio
- D. Hepatitis A
- E. Seasonal influenza
Correct Answer: B,C,E
Rationale: The correct recommendations to include are Varicella (B), Polio (C), and Seasonal influenza (E). Varicella vaccination prevents chickenpox, a common childhood illness. Polio vaccination is crucial to prevent the spread of polio, a highly contagious disease that can cause paralysis. Seasonal influenza vaccination is recommended to protect against the flu, which can be severe in young children. Haemophilus influenzae type b (A) is typically given in infancy, not preschool years. Hepatitis A (D) is recommended for older children and high-risk groups, not necessarily preschoolers.
As part of admission process
- A. nurse at long-term care facility is gathering nutrition history for client with dementia. Which component is priority to determine from their family?
- B. BMI
- C. Usual times for meals/snacks
- D. Favorite foods
- E. Any difficulty swallowing
Correct Answer: D
Rationale: The correct answer is D: Favorite foods. This is because knowing the client's favorite foods is crucial in ensuring they receive proper nutrition and enjoy their meals, especially for someone with dementia who may have difficulty remembering or expressing preferences. It helps enhance their quality of life and promotes adequate food intake.
Other choices are less critical:
A: Nutrition history can include various components, not just family input.
B: BMI is important but not the priority when gathering nutrition information.
C: Knowing meal/snack times is relevant but not as crucial as favorite foods.
E: Swallowing difficulty is important but not the priority in this scenario.
Nurse talking to parents of school-age child who describe many issues that concern them. Which problem should nurse identify as priority for more assessment & intervention?
- A. He doesn't keep up with other kids in activities like running & jumping
- B. He keeps trying to find ways around household rules, he always wants to make deals with us
- C. We think he is trying too hard to excel in math just to get top grades in his class
- D. He is always afraid the kids at school will laugh at him because he likes to sing & write poems
Correct Answer: A
Rationale: The correct answer is A. The nurse should identify the child's inability to keep up with other kids in physical activities as the priority for more assessment and intervention. This is because physical activity is crucial for a child's overall development and well-being. The inability to participate in activities like running and jumping could indicate underlying physical health issues, developmental delays, or coordination problems that need to be addressed promptly to prevent further complications. Choices B, C, and D are not as critical as they focus on behavioral or academic concerns which may be important but do not pose an immediate risk to the child's health and well-being.
Nurse transferring client from acute-care hospital to rehab facility. Which of following info about client should nurse include in transfer report?
- A. Alert & oriented
- B. Refuses to eat spinach
- C. Has shellfish allergy
- D. Requests morphine every 4h
- E. Misses the 2 cats he has at home
- F. allergies
- G. Alertness
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. A - Being alert and oriented is crucial for the client's safety and care continuity. C - Shellfish allergy is critical to prevent adverse reactions. D - Morphine request indicates pain management needs. Incorrect choices: B - Food preference is not a priority in transfer report. E - Missing pets is not pertinent medical information. F, G - General terms without specific details are not essential for transfer report.