Nokea
The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse?
- A. I think you or your partner needs to stay with the child while in the hospital.'
- B. Oh, that is expected, so I would just ignore the behavior.'
- C. Perhaps you could gradually leave for short periods.'
- D. You should leave quickly to minimize the child's distress.'
Correct Answer: C
Rationale: Gradually increasing the time of separation can help the child adjust to the mother's absence, reducing anxiety and screaming over time.
You may also like to solve these questions
A client with coronary artery disease is being seen in the clinic for a follow-up examination. During medication reconciliation, the nurse identifies which reported medication as requiring further investigation?
- A. 10 mg isosorbide dinitrate twice daily
- B. 20 mg atorvastatin once daily
- C. 500 mg naproxen twice daily
- D. 2,000 mg fish oil once daily
Correct Answer: C
Rationale: Naproxen (C), an NSAID, increases cardiovascular risk and bleeding, requiring investigation in coronary artery disease. Isosorbide (A), atorvastatin (B), and fish oil (D) are appropriate.
The nurse is teaching a group of parents about gross motor development of a 2-year old. According to the Denver Developmental Screening Test, which behavior is an example of the normal gross motor skill of a 2-year old?
- A. She can pull a toy behind her.
- B. She can copy a horizontal line.
- C. She can build a tower of eight blocks.
- D. She can broad jump.
Correct Answer: A
Rationale: Pulling a toy is a gross motor skill for a 2-year-old per the Denver Test. Copying a line and building a tower of eight blocks are fine motor skills. Broad jumping develops later.
A 4-year-old admitted with Wilms tumor is scheduled for a right nephrectomy in the morning. Which nursing action is a priority pre-operatively?
- A. Assessment of the child's emotional maturity level
- B. Auscultating for adventitious breath sounds
- C. Monitoring blood pressure closely
- D. Reinforcing instructions not to palpate the abdomen
Correct Answer: D
Rationale: Avoiding abdominal palpation (D) prevents tumor rupture in Wilms tumor, a critical pre-operative priority. Emotional assessment (A), lung sounds (B), and BP monitoring (C) are important but secondary.
The nurse is caring for a client with suspected acute rheumatic fever. Which of the following questions would be most important for the nurse to ask the client?
- A. Do you typically take all of your antibiotics when they are prescribed?
- B. Has anyone in your family had rheumatic fever?
- C. What has your temperature been over the past several days?
- D. Have you recently had a streptococcal throat infection?
Correct Answer: D
Rationale: Recent streptococcal infection (D) is the primary trigger for rheumatic fever, making it the most important question. Antibiotic compliance (A), family history (B), and fever (C) are relevant but less critical.
An 86-year-old client with diabetes and gastroparesis has had repeated hospitalizations for aspiration pneumonia following a stroke and is now hospitalized with altered level of consciousness. Which nursing action is most appropriate to decrease the client's risk for developing aspiration pneumonia?
- A. Assessing client's breath sounds every 2 hours
- B. Placing client in the side lying position in bed
- C. Titrating client's oxygen to maintain saturation 93%
- D. Turning and repositioning the client every 2 hours
Correct Answer: B
Rationale: The side-lying position (B) reduces aspiration risk by preventing reflux into the airway, especially in clients with altered consciousness. Assessing breath sounds (A), oxygen titration (C), and repositioning (D) are supportive but less effective for prevention.