Nokea
Sheena, tells the nurse that she wants to begin toilet training her 22-month-old child. The most important factor for the nurse to stress to the mother is:
- A. Developmental readiness of the child
- B. Consistency in approach
- C. The mother’s positive attitude
- D. Developmental level of the child’s peers
Correct Answer: A
Rationale: Developmental readiness is crucial for successful toilet training, as forcing it before the child is ready can lead to resistance and setbacks.
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Examples of cyanotic heart disease include:
- A. Ebstein's anomaly
- B. Pulmonary stenosis
- C. Coarctation of aorta
- D. Hypoplastic left heart syndrome
Correct Answer: D
Rationale: Hypoplastic left heart syndrome is a form of cyanotic heart disease. Ebstein's anomaly and pulmonary stenosis can also cause cyanosis, but coarctation of the aorta typically does not.
An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?
- A. Teach a family member to administer eye drops
- B. Encourage deep breathing and coughing exercises
- C. Provide an eye shield to be worn while sleeping
- D. Obtain vital signs every 2 hours during hospitalization
Correct Answer: C
Rationale: An eye shield protects the surgical site from accidental trauma during sleep, which is critical for postoperative healing.
A wide splitting of S2 during expiration is auscultated in a 2-week-old infant.
- A. Atrial septal defect (ASD)
- B. Coarctation of the aorta (COA)
- C. Patent ductus arteriosis (PDA)
- D. Ventricular septal defect (VSD)
Correct Answer: A
Rationale: A wide splitting of S2 without becoming a single sound on expiration may indicate increased pulmonary flow, typical of atrial septal defect.
A child born with Trisomy 21 should be evaluated for which associated cardiac manifestation?
- A. Systemic hypertension
- B. Congenital heart defect
- C. Hyperlipidemia
- D. Cardiomyopathy
Correct Answer: B
Rationale: Children with Trisomy 21 (Down syndrome) have a high incidence of congenital heart defects, such as atrioventricular septal defects, and should be evaluated for these conditions.
A client with draining skin lesions of the lower extremity is admitted with possible Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing interventions should the nurse include in the plan of care?
- A. Institute contact precautions for staff and visitors.
- B. Send wound drainage for culture and sensitivity.
- C. Monitor the client's white blood cell count.
- D. Administer broad-spectrum antibiotics before obtaining cultures.
Correct Answer: B
Rationale: MRSA requires contact precautions to prevent spread, culture and sensitivity testing is necessary to identify the specific organism, and WBC count should be monitored to assess for infection.