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Prior to discharge of a child with a ventriculoperitoneal (VP) shunt, the nurse reinforces teaching to the caregiver about when to contact the health care provider. The caregiver shows understanding of the instructions by contacting the health care provider about which symptom?
- A. A temperature of 98.6°F (37.2°C) that occurs during the evening
- B. The child cannot recall items eaten for lunch the previous day
- C. The child vomits after awakening from a nap and again 1 hour later
- D. The VP shunt is palpable along the posterolateral portion of the skull
Correct Answer: C
Rationale: Persistent vomiting (C) suggests shunt malfunction or increased intracranial pressure, requiring immediate reporting. Normal temperature (A), memory lapses (B), and palpable shunt (D) are not concerning.
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The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply.
- A. Age of 50
- B. Diagnosis of ovarian cancer
- C. Lying pulse 80/min, standing pulse 110/min
- D. Osteoarthritis of knees
- E. Takes carbidopa/levodopa
- F. Uses a cane to ambulate
Correct Answer: C,D,E
Rationale: Orthostatic pulse change (C) indicates cardiovascular instability, increasing fall risk. Osteoarthritis of knees (D) impairs mobility and stability. Carbidopa/levodopa (E) for Parkinson’s can cause orthostatic hypotension or dyskinesia, heightening fall risk. Age 50 (A) is not a significant risk factor alone, ovarian cancer (B) is unrelated to falls, and cane use (F) reduces risk if used correctly.
The nurse is planning care for all of the following clients. Which client should be cared for first?
- A. A 60-year-old who is three days postop and needs a dressing change and ambulation
- B. A 75-year-old who had a suprapubic prostatectomy yesterday and says, 'Take that tube out of me, I have to pee.'
- C. A 90-year-old who had a total hip replacement two days ago and is to get out of bed today
- D. A 50-year-old who had an abdominal cholecystectomy yesterday and is asking for pain medication
Correct Answer: B
Rationale: The 75-year-old post-prostatectomy client's request to remove the catheter and urgency to urinate suggest potential catheter obstruction or bladder irritation, which could lead to complications like infection or bladder damage. This requires immediate assessment and intervention, taking priority over routine dressing changes, scheduled mobility, or pain management.
The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women?
- A. Low tar cigarettes are less harmful during pregnancy
- B. There is a relationship between smoking and low birth weight
- C. The placenta serves as a barrier to nicotine
- D. Moderate smoking is effective in weight control
Correct Answer: B
Rationale: There is a relationship between smoking and low birth weight. Smoking reduces placental blood flow, contributing to fetal hypoxia and low birth weight.
A child with a high level of school absenteeism is diagnosed with separation anxiety disorder. The school nurse should remind the child’s parent to take what action?
- A. Allow the child to stay home when the child seems anxious
- B. Call the teacher to get the child’s schoolwork to do at home
- C. Have the child attend school, starting with a few hours a day
- D. Sit with the child in the classroom whenever possible
Correct Answer: C
Rationale: Gradual exposure to school, starting with partial attendance (C), helps desensitize the child to separation anxiety. Staying home (A) reinforces avoidance, schoolwork at home (B) delays reintegration, and parental presence (D) hinders independence.
The doctor has ordered Nitrostat (nitroglycerine) sublingually for a client with angina. The client should be ordered to replenish his supply every:
- A. 6 months
- B. 3 months
- C. 12 months
- D. 18 months
Correct Answer: A
Rationale: Nitroglycerin loses potency after 6 months, requiring replacement to ensure efficacy for angina relief.