Nokea
An 11-year-old boy with a minor head injury treated at the outpatient clinic.
The nurse determines that further teaching is necessary if the mother makes which of the following statements? dimensional visualization of the vertebral canal.'
- A. My son may have dizziness for 24 hours.'
- B. My son can drink carbonated beverages if he vomits.'
- C. My son may complain of nausea.'
- D. My son will probably have a headache.'
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to a minor head injury. (1) expected for at least 24 hours (2) correct-unexpected, should be reported to physician immediately, also unexpected is blurred vision, drainage from ear or nose, weakness, slurred speech, worsening headache (3) expected for at least 24 hours (4) expected for at least 24 hours, should not get more intense
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During the development of a nursing care plan, the nurse should consider which of the following clients for the use of a restraint?
- A. An infant with septicemia.
- B. A child with a tonsillectomy.
- C. An infant with cleft lip repair.
- D. A child with meningitis.
Correct Answer: C
Rationale: arm restraints are necessary to prevent infant from rubbing or otherwise disturbing suture line
The nurse is caring for a client who is postoperative day 1 after a mastectomy. Which of the following actions is the PRIORITY?
- A. Encourage the client to perform arm exercises.
- B. Administer pain medication as needed.
- C. Monitor the surgical drain for output.
- D. Check the incision for redness.
Correct Answer: A
Rationale: Encouraging arm exercises is the priority to prevent lymphedema and restore mobility post-mastectomy. Options B, C, and D are important but secondary: pain management, drain monitoring, and incision checks follow mobility promotion.
In providing care to a 14 year-old adolescent with scoliosis, which of the following will be most difficult for this client?
- A. Compliance with treatment regimens
- B. Looking different from their peers
- C. Lacking independence in activities
- D. Reliance on family for their social support
Correct Answer: B
Rationale: Looking different from their peers. Conformity is critical at age 14, and visible differences due to scoliosis treatment can be challenging.
A low-income client needing to satisfy essential protein needs.
Which of the following foods would the nurse encourage a low-income client to eat to satisfy essential protein needs?
- A. Legumes.
- B. Red meat.
- C. Seafood.
- D. Cheese.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-legumes are an economical source rich in protein (2) high in protein, but more expensive to purchase (3) high in protein, but more expensive to purchase (4) high in protein, but more expensive to purchase
A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client is using the mechanism of 'suppression'?
- A. I don't remember anything about what happened to me.
- B. I'd rather not talk about it right now.
- C. It's all the other guy's fault! He was going too fast.
- D. My mother is heartbroken about this.
Correct Answer: A
Rationale: I don't remember anything about what happened to me. Suppression is willfully putting an unacceptable thought or feeling out of one's mind, used to protect one's self-esteem.