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Parents of young children often need anticipatory guidance from the nurse. Parents may have little knowledge regarding growth and development. Which of the following toys and activities would the nurse suggest as appropriate for a toddler?
- A. Cutting, pasting, string beads, music, dolls
- B. Mobiles, rattle, squeeze toys
- C. Pull-toys, large ball, dolls, sand and water play, music
- D. Simple card games, puzzles, bicycle, television
Correct Answer: C
Rationale: These activities provide the toddler (1-3 years old) with a variety of physical activities for play, suitable for their developmental stage.
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A client with a history of trigeminal neuralgia is admitted with complaints of facial pain. The nurse should give priority to:
- A. Administering analgesics
- B. Monitoring blood pressure
- C. Providing a quiet environment
- D. Administering oxygen
Correct Answer: A
Rationale: Trigeminal neuralgia causes severe facial pain, so administering analgesics is the priority to relieve discomfort.
The physician has ordered a low-sodium diet for a client with hypertension. Which food should the nurse instruct the client to avoid?
- A. Fresh fruit
- B. Grilled chicken
- C. Canned soup
- D. Brown rice
Correct Answer: C
Rationale: Canned soups are high in sodium, which exacerbates hypertension. Fresh fruit, grilled chicken, and brown rice are low-sodium options suitable for a hypertension diet.
The nurse is teaching a client with a history of migraines about trigger avoidance. The nurse should tell the client to avoid:
- A. Chocolate
- B. Fresh vegetables
- C. Lean meats
- D. Whole grains
Correct Answer: A
Rationale: Chocolate is a common migraine trigger, potentially causing vasoconstriction or neurotransmitter changes, so it should be avoided.
A client with a history of a heart transplant is receiving Cyclosporine (Sandimmune). The nurse should monitor the client for:
- A. Infection
- B. Hypotension
- C. Hyperkalemia
- D. Weight loss
Correct Answer: A
Rationale: Cyclosporine suppresses immunity, increasing infection risk, requiring vigilant monitoring. Hypotension, hyperkalemia, and weight loss are less common.
A 24-year-old graduate student recognizes that he has a phobia傳He suffers severe anxiety when he is in darkness. It has altered his lifestyle because he is unable to go to a movie theater, concert, and other events that may require absence of light. The client is seeking assistance because he is no longer able to socialize with friends due to his phobia. The psychologist working with him is using desensitization. He has asked the nursing staff to assist the client in muscle relaxation techniques. What result would indicate client education has been successful?
- A. He enters a movie theater, sits in his chair, and replaces anxiety with relaxation as the theater darkens.
- B. He enters a concert, but as the lights dim, he does not experience anxiety.
- C. He states that he no longer fears dark places.
- D. He takes a part-time job as a photographic assistant. His job necessitates his working in a darkroom.
Correct Answer: A
Rationale: This situation provides specific evidence that the client is able to integrate muscle relaxation technique into his lifestyle to alleviate anxiety. The client may not experience anxiety at the concert, but there is no evidence regarding the technique that he used to alleviate anxiety. The client may state he no longer experiences anxiety, but there is no evidence demonstrating this. He may be denying anxiety to discontinue therapy prematurely. Does he experience anxiety in the darkroom? He may have taken this job to force himself to deal with the phobia directly.