Nokea
The nurse has reinforced teaching with the parents of a 6-year-old client with chronic allergic rhinitis that is triggered by dust and pollen. Which of the following statements by the parents would indicate a correct understanding of the teaching? Select all that apply.
- A. We are planning to purchase an air purifier with a high-efficiency particulate air filter
- B. We will keep the windows open during warm weather to air out our house.
- C. We should place hypoallergenic covers on our child's mattress and pillow.
- D. We will clean our wood floors with a damp mop at least once a week
- E. We are planning to remove the carpet from our child's bedroom.
Correct Answer: A,C,D,E
Rationale: Correct choices reduce allergen exposure: HEPA filters remove dust/pollen, hypoallergenic covers prevent dust mite exposure, damp mopping reduces dust, and removing carpets eliminates allergen reservoirs. Keeping windows open increases pollen exposure, worsening symptoms.
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A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
- A. Document the finding.
- B. Report the finding to the doctor.
- C. Prepare the client for a C C-section.
- D. Continue primary care as prescribed.
Correct Answer: B
Rationale: Any lesion should be reported to the doctor. This can indicate a herpes lesion. Clients with open lesions related to herpes are delivered by Cesarean section because there is a possibility of transmission of the infection to the fetus with direct contact to lesions. It is not enough to document the finding, so answer A is incorrect. The physician must make the decision to perform a C-section, making answer C incorrect. It is not enough to continue primary care, so answer D is incorrect.
The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be
- A. High calorie, low fat, low sodium
- B. High protein, low fat, low carbohydrate
- C. High protein, high calorie, unrestricted fat
- D. High carbohydrate, low protein, moderate fat
Correct Answer: C
Rationale: High protein, high calorie, unrestricted fat. The child with Cystic Fibrosis needs a well balanced diet that is high in protein and calories. Fat does not need to be restricted.
A nurse is planning to complete a physical examination of a toddler. Which approach is an appropriate intervention by the nurse?
- A. Encourage the parent to be involved with the child
- B. Engage in physical contact by removing the toddler's outer clothing first
- C. Have medical equipment lying on a counter within view
- D. Perform an examination in a head-to-toe order
Correct Answer: A
Rationale: Parental involvement reduces toddler anxiety during exams. Removing clothing first, visible equipment, or strict head-to-toe order may increase distress.
An obese 85-year-old client, who is an avid gardener and eats only home-grown fruits, legumes, and vegetables, is admitted to the hospital with pneumonia after having an upper respiratory tract infection for a week. Which factor puts the client at greatest risk for developing pneumonia?
- A. Advanced age
- B. Environmental exposure
- C. Nutritional deficit
- D. Obesity
Correct Answer: A
Rationale: Advanced age (85 years) is the greatest risk factor for pneumonia due to weakened immune response and comorbidities. Other factors are less significant.
The nurse is attending an end-of-year school family picnic. Which situation needs an immediate intervention?
- A. A 2-year-old eating a hot dog unsupervised
- B. A 3-year-old playing alone in a wading pool
- C. A 4-year-old tossing a beach ball
- D. A 5-year-old climbing on monkey bars
Correct Answer: B
Rationale: A 3-year-old alone in a wading pool is at immediate risk of drowning, requiring urgent intervention. A poses a choking risk but is less immediately life-threatening. C and D are age-appropriate activities with lower immediate risk.