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The most important goal in the care plan for a child who was hospitalized with an accidental overdose would be to:
- A. Determine child's activity pattern
- B. Reduce mother's sense of guilt
- C. Instruct parents in use of ipecac
- D. Teach parents appropriate safety precautions
Correct Answer: D
Rationale: This goal is not the most important. There is always some guilt when an accident occurs; however, the priority is to be sure future accidents are prevented. Ipecac is not used for caustic alkali and acid ingestions. Determining the parent's knowledge about safety hazards and teaching appropriate preventive measures are likely to prevent recurrence of accidents.
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The nurse is teaching a client with a history of migraines about trigger avoidance. The nurse should tell the client to avoid:
- A. Chocolate
- B. Fresh vegetables
- C. Lean meats
- D. Whole grains
Correct Answer: A
Rationale: Chocolate is a common migraine trigger, potentially causing vasoconstriction or neurotransmitter changes, so it should be avoided.
A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:
- A. Uses an electric blanket at night
- B. Dresses in extra layers of clothing
- C. Applies a heating pad to her feet
- D. Takes a hot bath morning and evening
Correct Answer: B
Rationale: Dressing in extra layers is a safe, effective way to manage cold intolerance in hypothyroidism by conserving body heat. Electric blankets and heating pads pose burn risks, and baths are temporary.
Which one of the following situations represents a maturational crisis for the family?
- A. A four-year-old entering nursery school
- B. Development of preeclampsia during pregnancy
- C. Loss of employment and health benefits
- D. Hospitalization of a grandfather with a stroke
Correct Answer: A
Rationale: A maturational crisis involves normal developmental transitions, such as a child entering nursery school, which can stress family dynamics.
A client is having episodes of hyperventilation related to her surgery that is scheduled tomorrow. Appropriate nursing actions to help control hyperventilating include:
- A. Administering diazepam (Valium) 10-15 mg po q4h and q1h prn for hyperventilating episode
- B. Keeping the temperature in the client's room at a high level to reduce respiratory stimulation
- C. Having the client hold her breath or breathe into a paper bag when hyperventilation episodes occur
- D. Using distraction to help control the client's hyperventilation episodes
Correct Answer: C
Rationale: An adult diazepam dosage for treatment of anxiety is 2-10 mg PO 2-4 times daily. The order as written would place a client at risk for overdose. A high room temperature could increase hyperventilating episodes by stimulating the respiratory system. Breath holding and breathing into a paper bag may be useful in controlling hyperventilation. Both measures increase CO2 retention. Distraction will not prevent or control hyperventilation caused by anxiety or fear.
The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is:
- A. Body image disturbance related to enlargement of the neck
- B. Activity intolerance related to fatigue
- C. Nutrition imbalance, less than body requirements, related to increased metabolism
- D. Risk for ineffective airway clearance related to pressure of goiter on the trachea
Correct Answer: D
Rationale: A large goiter can compress the trachea, posing a risk for ineffective airway clearance, which is a priority due to its potential to impair breathing.