Nokea
The father of a 3-week-old infant who has developed sepsis says that he feels guilty because he did not realize his infant was sick. Which of the following responses by the nurse would be most appropriate?
- A. You should have realized something was wrong; he is your son.'
- B. Did you read the booklet on newborns that was sent home with you from the hospital?'
- C. What you're feeling is normal; next time, you will know what to look for.'
- D. Babies can get sick quickly, and parents do not always realize it.'
Correct Answer: D
Rationale: Reassuring the father that infants can become ill rapidly and that it's not always obvious validates his feelings and provides education without blame.
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A client with a history of rheumatoid arthritis is prescribed hydroxychloroquine (Plaquenil). The nurse should instruct the client to:
- A. Have regular eye exams.
- B. Take the medication on an empty stomach.
- C. Avoid calcium-rich foods.
- D. Stop the medication if joint pain resolves.
Correct Answer: A
Rationale: Hydroxychloroquine can cause retinal toxicity, requiring regular eye exams.
A 5-year-old child is admitted with a fever and rash. The nurse suspects scarlet fever. Which assessment finding supports this diagnosis?
- A. Strawberry tongue
- B. Koplik spots
- C. Vesicular rash
- D. Pustules on the trunk
Correct Answer: A
Rationale: Strawberry tongue is a characteristic sign of scarlet fever, caused by group A Streptococcus, aiding in diagnosis confirmation.
A client being mechanically ventilated after experiencing a fat embolus is visibly anxious. Which action should the nurse take?
- A. Remain with the client and provide reassurance.
- B. Ask a family member to stay with the client at all times.
- C. Encourage the client to sleep until arterial blood gas results improve.
- D. Ask the primary health care provider to write a prescription for an antianxiety medication.
Correct Answer: A
Rationale: The nurse always speaks to the client calmly and provides reassurance to the anxious client. Family members are also stressed because of the severity of the situation; therefore, it is not beneficial to ask the family to take on the burden of remaining with the client at all times. Encouraging the client to sleep will not assist in relieving the client's anxiety. Antianxiety medications are used only if necessary and if other interventions fail to relieve the client's anxiety.
A 6-year-old child is admitted to the hospital for heart surgery to repair tetralogy of Fallot. The child asks the nurse if the cardiac catheterization will hurt. Which of the following statements offers the nurse the best guide for responding to the child's question?
- A. The medication used to numb the insertion site will sting
- B. Momentary sharp pain usually occurs when the catheter enters the heart
- C. It is usual for a 6-year-old to feel discomfort during the procedure
- D. It is a painless procedure, although a tingling sensation may be felt in the extremities
Correct Answer: A
Rationale: The local anesthetic used at the insertion site for cardiac catheterization may cause a stinging sensation, which is an honest and appropriate response for a 6-year-old. Pain is not typically felt when the catheter enters the heart, and discomfort or tingling is not a standard experience.
The nurse is teaching a client about warfarin (Coumadin) therapy. Which food should the client avoid?
- A. Spinach
- B. Chicken breast
- C. Brown rice
- D. Apples
Correct Answer: A
Rationale: Spinach is high in vitamin K, which can antagonize warfarin's anticoagulant effect, requiring dietary consistency to maintain therapeutic INR levels.