Nokea
The healthcare provider is preparing to suture a 10-year-old child with a lacerated forehead. Both parents and a 12-year-old sibling are present at the child's bedside. Which instruction best supports family involvement?
- A. While waiting for the healthcare provider, only one visitor may stay with the child.
- B. All of you should leave while the healthcare provider sutures the child's forehead.
- C. It is best if the sibling goes to the waiting room until the suturing is completed.
- D. Please decide who will stay when the healthcare provider begins suturing.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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When developing a behavior modification program for an extremely aggressive 10-year-old boy, what should the nurse do first?
- A. Identify what activities, foods, and toys the child enjoys
- B. Assess the child's previous reactions to punishment
- C. Offer the child positive feedback
- D. Involve other children on the unit in describing the token system
Correct Answer: A
Rationale: The first step in developing a behavior modification program for an extremely aggressive 10-year-old boy is to identify what activities, foods, and toys the child enjoys. Understanding the child's motivations is crucial in creating an effective behavior modification plan tailored to his interests and preferences, which can help in positively reinforcing desired behaviors.
A 16-year-old female student with a history of asthma controlled with both an oral antihistamine and an albuterol (ProAir) metered-dose inhaler (MDI) comes to the school nurse. The student complains that she cannot sleep at night, feels shaky, and her heart feels like it is 'beating a mile a minute.' Which information is most important for the nurse to obtain?
- A. When she last took the antihistamine.
- B. When her last asthma attack occurred.
- C. Duration of most asthma attacks.
- D. How often the MDI is used daily.
Correct Answer: D
Rationale: The most crucial information for the nurse to obtain in this scenario is how often the metered-dose inhaler (MDI) is used daily. This information will help assess if the symptoms of insomnia, shakiness, and palpitations are potentially related to overuse of the inhaler, which can cause side effects such as tremors and palpitations. Monitoring the frequency of MDI usage is essential in managing asthma and ensuring appropriate medication administration.
A 2-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?
- A. Determine the pulse deficit.
- B. Administer the scheduled dose.
- C. Calculate the safe dose range.
- D. Review the serum digoxin level.
Correct Answer: B
Rationale: Administering the scheduled dose is appropriate in this scenario since the heart rate of 128 bpm is within an acceptable range for a 2-year-old child with heart failure. Monitoring for signs of digoxin toxicity is important; however, the immediate action required is to administer the scheduled dose as prescribed based on the heart rate assessment.
A 5-year-old child with leukemia is receiving chemotherapy. The nurse notes that the child's white blood cell count is low. What is the nurse's priority intervention?
- A. Administer antibiotics as prescribed
- B. Place the child in protective isolation
- C. Encourage the child to eat a balanced diet
- D. Teach the parents about infection prevention
Correct Answer: B
Rationale: The priority intervention for a 5-year-old child with leukemia receiving chemotherapy and having a low white blood cell count is to place the child in protective isolation. This intervention helps reduce the risk of infection, which is crucial in this immunocompromised state. Protective isolation aims to limit the child's exposure to pathogens and promote their safety during a period of increased vulnerability to infections.
A 2-year-old boy begins to cry when the mother starts to leave. What is the nurse's best response in this situation?
- A. Let me read this book to you.
- B. Two years old usually stop crying the minute the parent leaves.
- C. Now be a big boy. Mommy will be back soon.
- D. Let's wave bye-bye to mommy.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.