Nokea
The nurse admits a 2 year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure?
- A. He has been taking long naps for a week.'
- B. He has had an ear infection for the past 2 days.'
- C. He has been eating more red meat lately.'
- D. He seems to be going to the bathroom more frequently.'
Correct Answer: B
Rationale: He has had an ear infection for the past 2 days.' Contributing factors to seizures in children include those such as age (more common in first 2 years), infections (late infancy and early childhood), fatigue, not eating properly and excessive fluid intake or fluid retention.
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The nurse is caring for a depressed client with a new prescription for a selective serotonin reuptake inhibitor (SSRI) antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication?
- A. History of obesity
- B. Prescribed use of a monoamine oxidase (MAO) inhibitor
- C. Diagnosis of vascular disease
- D. Takes antacids frequently
Correct Answer: B
Rationale: SSRIs should not be taken concurrently with MAO inhibitors because serious, life-threatening reactions may occur with this combination of drugs.
The nurse is reinforcing education about home care to the parent of a 10-year-old with cystic fibrosis. Which of the following statements by the parent indicates that teaching has been effective? Select all that apply.
- A. Chest physiotherapy is administered only if respiratory symptoms worsen.
- B. I will give my child pancreatic enzymes with all meals and snacks.
- C. I will increase my child's salt intake during hot weather.
- D. Our child will need a high-carbohydrate, high-protein diet.
- E. We will limit our child's participation in sports activities.
Correct Answer: B,C,D
Rationale: Pancreatic enzymes with meals (B), increased salt in hot weather (C), and a high-calorie, high-protein diet (D) are correct for cystic fibrosis management. Chest physiotherapy (A) is routine, not symptom-based, and limiting sports (E) is unnecessary unless advised.
The client is admitted for a bronchoscopy this morning. Which question is essential for the nurse to ask the client?
- A. When did you last eat?'
- B. Did you take the laxative as ordered?'
- C. What has the doctor told you about your procedure?'
- D. Have you had conscious sedation before?'
Correct Answer: A
Rationale: Bronchoscopy requires NPO status to prevent aspiration; confirming last intake is essential. Laxatives, procedure knowledge, or sedation history are secondary.
The nurse is reinforcing teaching to parents about childhood nutrition and feeding practices. The nurse recognizes that which snack is best for a toddler?
- A. 1/2 cup orange juice
- B. Dry, sweetened cereal
- C. Raw carrot sticks
- D. Slice of cheese
Correct Answer: D
Rationale: A slice of cheese (D) is a nutrient-dense, easy-to-chew snack suitable for a toddler, providing protein and calcium. Orange juice (A) is high in sugar, sweetened cereal (B) lacks nutritional value, and raw carrot sticks (C) pose a choking hazard.
A 24-year-old female client is prescribed isotretinoin for severe cystic acne. Which instruction is most important for the nurse to reinforce?
- A. Apply lubricating eye drops when wearing contacts
- B. Do not break, crush, or chew capsules
- C. Use sunscreen routinely during therapy
- D. Use two forms of contraception consistently
Correct Answer: D
Rationale: Isotretinoin is highly teratogenic, so using two forms of contraception (D) is critical to prevent pregnancy. Sunscreen (C) is important for photosensitivity, but contraception is the priority.