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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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Which of the following statements is incorrect regarding shock?
- A. In cardiogenic shock systemic vascular resistance is high
- B. In hypovolemic shock pulmonary capillary wedge pressure is reduced
- C. In distributive shock central venous pressure is increased
- D. In hypovolemic shock mean arterial pressure is normal
Correct Answer: D
Rationale: In hypovolemic shock
Nurse Oliver s teaching a mother who plans to discontinue breast-feeding after 5 months. The nurse should advise her to include which foods in her infant’s diet?
- A. Iron-rich formula and baby food
- B. Whole milk and baby food
- C. Skim milk and baby food
- D. Iron-rich formula only
Correct Answer: A
Rationale: Iron-rich formula and baby food provide essential nutrients for a 5-month-old infant transitioning from breastfeeding.
The nurse is preparing to administer enoxaparin (Lovenox) 135 mg subcutaneously. The medication is available in a cartridge labeled 150 mg/ml. How many ml should the nurse administer? (enter numeric value only. If rounding is required, round to the nearest tenth.)
- A. 0.9
- B. 1
- C. 9
Correct Answer: A
Rationale: The calculation is based on the prescribed dose and the concentration of the medication.
Which information should the nurse know when caring for a child with Kawasaki disease?
- A. A child’s fever is usually responsive to antibiotics within 48 hours.
- B. The principal area of involvement is the joints.
- C. Aspirin is contraindicated.
- D. Therapeutic management includes administration of gamma globulin and aspirin.
Correct Answer: D
Rationale: High-dose IV gamma globulin and aspirin therapy is indicated to reduce the incidence of coronary artery abnormalities when given within the first 10 days of the illness. The fever of Kawasaki disease is unresponsive to antibiotics and antipyretics. Mucous membranes, conjunctiva, changes in the extremities, and cardiac involvement are seen. Aspirin is part of the therapy.
To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), what interventions should the nurse implement?
- A. Initiate passive range of motion exercises
- B. Establish a regular bladder routine
- C. Teach the client breathing exercises
- D. Perform chest physiotherapy
Correct Answer: C
Rationale: Breathing exercises, chest physiotherapy, and use of an incentive spirometer can help reduce the risk of pulmonary complications in ALS by improving lung function.