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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.
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A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to an AP?
- A. Feeding client admitted 24h ago with aspiration pneumonia
- B. Reinforcing teaching with client learning to walk using a quad cane
- C. Reapplying a condom catheter for a client with urinary incontinence
- D. Applying sterile dressing to a pressure ulcer
Correct Answer: C
Rationale: The correct answer is C: Reapplying a condom catheter for a client with urinary incontinence. This task involves non-invasive, routine care that can be safely delegated to an assistive personnel (AP). The nurse should ensure that the AP is trained and competent in performing this procedure.
Choice A: Feeding a client with aspiration pneumonia requires assessment and monitoring for signs of aspiration, which should be done by a licensed nurse due to the risk of complications.
Choice B: Reinforcing teaching with a client using a quad cane involves critical thinking, assessment of the client's understanding, and ensuring safety, which should be done by a licensed nurse.
Choice D: Applying a sterile dressing to a pressure ulcer requires sterile technique, assessment of wound status, and potential need for wound care interventions, which should be performed by a licensed nurse.
A mother tells nurse that her 2 yo has temper tantrums. Child says 'no' every time mother tries to help her get dressed. Nurse explains that developmentally the toddler is...
- A. Trying to gain her independence
- B. Developing sense of trust
- C. Manifesting anger management problem
- D. Attempting to finish a project she started
Correct Answer: A
Rationale: The correct answer is A: Trying to gain her independence. This is because at the age of 2, children often exhibit behaviors such as saying 'no' and resisting help as they start to assert their independence and autonomy. This behavior is a normal part of their development as they strive to explore their own abilities and assert control over their environment. Choices B, C, and D are incorrect because at this age, the child is not yet focused on developing a sense of trust, managing anger, or finishing projects. It is important to recognize and support the child's need for independence while providing guidance and setting appropriate boundaries.
Nurse is teaching young adult about health promotion & illness prevention. Which client statement indicates understanding?
- A. I already had my immunizations as a child, so I'm protected in that area.
- B. It's important to schedule routine healthcare visits even if I'm feeling well
- C. If I'm having any discomfort, I'll just go to an urgent care center
- D. If I'm feeling stressed, I will remind myself that this is something I should expect
Correct Answer: B
Rationale: The correct answer is B: It's important to schedule routine healthcare visits even if I'm feeling well. This statement indicates understanding of health promotion and illness prevention as it emphasizes the importance of preventive care and early detection of potential health issues. By attending routine healthcare visits, the individual can monitor their health status, receive necessary screenings, and address any underlying health concerns before they escalate.
Choice A is incorrect because having immunizations as a child does not provide lifelong protection against all diseases. Choice C is incorrect as urgent care centers are typically for urgent medical needs, not routine preventive care. Choice D is incorrect as stress management is important, but it does not directly relate to health promotion and illness prevention.
Nurse has removed sterile pack from its outside cover & placed it on clean work surface in prep for invasive procedure. Which of following flaps should nurse unfold first?
- A. Flap closest to body
- B. Right side flap
- C. Left side flap
- D. Flap farthest from the body
Correct Answer: D
Rationale: The correct answer is D: Flap farthest from the body. The rationale is to maintain sterility. By unfolding the flap farthest from the body first, the nurse can avoid reaching over the sterile field, minimizing the risk of contamination. This step-by-step approach ensures that the sterile pack remains uncontaminated and ready for the invasive procedure. Unfolding the closest flap, right side flap, or left side flap first would require the nurse to lean over the sterile field, increasing the chances of contamination. Therefore, choosing the flap farthest from the body is the most logical and sterile technique in this situation.
Nurse contributing to care plan for client being admitted to facility with suspected dx of pertussis. Which should nurse include in care plan?
- A. Place client in room with negative air pressure of at least 6 exchanges per hour
- B. Wear mask when providing care within 3 ft of client
- C. Place mask on client if transportation to another dept is unavoidable
- D. Use sterile gloves when handling soiled linens
- E. Wear gown when performing care that may result in contamination from secretions
Correct Answer: B,C,E
Rationale: The correct answer includes wearing a mask when providing care within 3 feet of the client to prevent the spread of pertussis through respiratory droplets. Placing a mask on the client during unavoidable transportation helps reduce exposure to others. Wearing a gown when performing care that may result in contamination from secretions is essential to prevent transmission through contact. Choice A is incorrect because negative air pressure is not necessary for pertussis isolation. Choice D is unnecessary as pertussis is not transmitted through contact with soiled linens.