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The nurse caring for a child diagnosed with leukemia notes that the platelet count is 20,000 mm3 (20 x 10^9/L). Based on this finding, the nurse should include which interventions in the plan of care? Select all that apply.
- A. Monitor stools for blood.
- B. Clean oral cavity with soft swabs.
- C. Provide appropriate play activities.
- D. Check the rectal temperature every 4 hours.
- E. Administer acetaminophen suppositories for fever.
Correct Answer: A,B,C
Rationale: A platelet count of 20,000 mm3 (20 x 10^9/L) places the child at risk for bleeding. The remaining options 1, 2, and 3 are accurate interventions. Taking rectal temperatures and the use of suppositories are avoided because of the risk of rectal bleeding.
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You have decided to use the Dimensions Model of Health model to assess, monitor and evaluate the health status of the community. Which of these dimensions is NOT an element of this Dimensions Model of Health model?
- A. The Biophysical Dimension
- B. The Psychological and Emotional Dimension
- C. The Spiritual Dimension
- D. The Health Systems Dimension
Correct Answer: D
Rationale: The Dimensions Model of Health typically includes biophysical, psychological, social, and spiritual dimensions. The Health Systems Dimension is not a standard component of this model.
A client is prescribed buspirone (BuSpar) 5mg two times a day. Which of the following statements indicates that the client has understood the nurse's teaching about this drug? Select all that apply.
- A. This medicine will make me sleepy
- B. BuSpar will relax my muscles
- C. My anxiety will be completely gone by tomorrow
- D. BuSpar will help me not to worry so much
- E. I'll be able to focus better
Correct Answer: D,E
Rationale: Buspirone reduces anxiety and improves focus without causing sedation or muscle relaxation. Expecting complete anxiety relief by tomorrow is unrealistic, as it takes weeks to be effective.
The nurse is teaching an unlicensed assistive personnel about the care of clients with self-mutilation. Which of the following, if stated by the unlicensed personnel about self-mutilation, demonstrates that the teaching has been effective?
- A. It is a means of getting what the person wants.'
- B. It is a nonserious event that can be ignored.'
- C. It is a way to express anger and rage.'
- D. It is a form of manipulation.'
Correct Answer: C
Rationale: Self-mutilation is often a way to express intense emotions like anger or rage, indicating the assistant understands its emotional significance.
Select the age group that is accurately paired with the normal and recommended hours of sleep each day.
- A. The neonate: 10 to 15 hours a day
- B. The toddler: 11 to 14 hours a day
- C. The preschool child: 12 to 15 hours a day
- D. The school age child: Less than 8 hours a day
Correct Answer: B
Rationale: Toddlers (1-2 years) typically require 11-14 hours of sleep per day, including naps, which is the correct pairing.
The nurse is caring for a client with a closed head injury. Which finding indicates increasing intracranial pressure?
- A. Widening pulse pressure
- B. Tachycardia
- C. Hyperthermia
- D. Hypotension
Correct Answer: A
Rationale: Widening pulse pressure (e.g., increasing systolic with stable diastolic) is a sign of increasing intracranial pressure, part of Cushing's triad.