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The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:
- A. Place tape on the child's perianal area before putting the child to bed
- B. Scrape the skin with a piece of cardboard and bring it to the clinic
- C. Obtain a stool specimen in the afternoon
- D. Bring a hair sample to the clinic for evaluation
Correct Answer: A
Rationale: The tape test, applied to the perianal area at night or early morning, is the standard method to collect pinworm eggs.
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A nurse working in ICU has a client on a propofol (Diprivan) drip while on the mechanical ventilator. The nurse needs another bottle, which must be picked up in person in the hospital pharmacy. Which is the correct action by the nurse concerning this medication?
- A. ask the unit secretary to go to the pharmacy and pick it up
- B. send the unlicensed assistive personnel (UAP) to pick it up since the nurse is busy
- C. ask the client's health care provider to bring it when he or she rounds on the client
- D. ask another nurse to watch the clients while the nurse goes to the pharmacy to get the medication
Correct Answer: D
Rationale: The nurse must ensure continuous client monitoring, so asking another nurse to cover while retrieving the controlled medication is the safest action.
In many cultures, pregnancy is viewed as a natural rather than a medical condition. How does this affect prenatal care?
- A. Pregnant women often seek prenatal care later and less frequently.
- B. These views have little effect on prenatal care.
- C. Pregnant women believe prenatal care is harmful to the fetus.
- D. These views often result in increased rates of fetal mortality.
Correct Answer: A
Rationale: Viewing pregnancy as natural (A) often leads to delayed or less frequent prenatal care, impacting monitoring. Harmful beliefs (C) or increased mortality (D) are not directly implied.
A 6-year-old with cerebral palsy functions at the level of an 18-month-old. Which finding would support that assessment?
- A. She dresses herself.
- B. She pulls a toy behind her.
- C. She can build a tower of eight blocks.
- D. She can copy a horizontal or vertical line.
Correct Answer: B
Rationale: Pulling a toy is consistent with an 18-month-old's developmental level, supporting the assessment.
The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time?
- A. Confirm that all staff members understand and comply with the treatment plan.
- B. Establish mutually agreed upon, realistic goals.
- C. Ensure that the potent reinforcers (rewards) are important to the client.
- D. Establish a fixed interval schedule for reinforcement.
Correct Answer: A
Rationale: to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program
The nurse is caring for an elderly client who presents to the ED with poor appetite, confusion, and weakness. Lab work is ordered for the client. The nurse should immediately notify the health care provider for which lab result?
- A. chloride 99 mEq/L
- B. calcium 9.4 mg/dL
- C. sodium 118 mEq/L
- D. potassium 4.2 mEq/L
Correct Answer: C
Rationale: Severe hyponatremia (sodium 118 mEq/L) can cause confusion and weakness and requires immediate provider notification. Other values are within normal ranges.