Nokea
The nurse in a clinic is caring for an 8-month-old client with a new diagnosis of bronchiolitis due to respiratory syncytial virus. Which of the following instructions should the nurse provide to the parent?
- A. Administration of a cough suppressant and an antihistamine
- B. Prophylactic treatment of family members
- C. Temporary cessation of breastfeeding
- D. Use of saline drops and a bulb syringe to suction nares
Correct Answer: D
Rationale: For bronchiolitis due to RSV, saline drops and bulb syringe suctioning help clear nasal passages, improving breathing. Cough suppressants and antihistamines are not recommended as they may suppress necessary cough or cause sedation. Prophylactic treatment is not standard for family members unless immunocompromised, and breastfeeding should continue to provide antibodies.
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The nurse has attended a staff education program about narcissistic personality disorder (NPD). The nurse should understand that clients with NPD
- A. experience a fear of abandonment and have a fragile self-esteem
- B. may require medication to manage hallucinations
- C. demonstrate magical thinking and feelings of depersonalization
- D. experience episodes of acute anxiety
Correct Answer: A
Rationale: Clients with NPD typically have a fragile self-esteem masked by grandiosity and may fear abandonment . Hallucinations are not characteristic, magical thinking aligns more with schizotypal personality disorder, and acute anxiety is less specific.
A woman is being seen in the physician's office for a medical complaint. When she is called to see the physician, she goes to the restroom and washes her hands over and over, missing her allotted time with the physician. How should the nurse deal with this woman?
- A. Send her home without seeing the doctor if she is not available when called
- B. Give her advance warning that she will be seeing the physician and tell her that if she needs to wash her hands, she should do so
- C. Interrupt her washing ritual and insist that she see the physician when it is her turn
- D. Give her a choice of seeing the physician or washing her hands
Correct Answer: B
Rationale: Advance warning accommodates possible OCD, allowing hand washing within a timeframe, ensuring she sees the physician. Sending home, interrupting, or forcing choices is less effective.
The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet
- A. High in carbohydrates and proteins
- B. Low in carbohydrates and proteins
- C. High in carbohydrates, low in proteins
- D. Low in carbohydrates, high in proteins
Correct Answer: A
Rationale: High in carbohydrates and proteins. This diet supports energy needs and compensates for malabsorption in cystic fibrosis.
Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report? Select all that apply.
- A. Administered 9.00 AM medication at 9.30 AM
- B. Developed worsening cellulitis after missing antibiotics for 1 day
- C. Has a seizure and a history of epilepsy
- D. Slides off the edge of the bed and ends up sitting on the floor
- E. Waits 4 hours to be transported for STAT diagnostic CT scan
Correct Answer: B,D,E
Rationale: Adverse events requiring an incident report include worsening cellulitis due to missed antibiotics , a fall even without injury , and a significant delay in a STAT procedure . Late medication administration is a variance but not typically an adverse event unless harm occurs, and a seizure in a known epileptic is expected unless protocol was not followed.
An 80-year-old woman is having difficulty sleeping. Which nursing action is most appropriate initially?
- A. Ask the physician for an order for a sleeping medication.
- B. Encourage the client to do mild exercises a half hour before going to bed.
- C. Suggest to the client that she not nap during the day.
- D. Recommend the client drink coffee in the evening.
Correct Answer: C
Rationale: Avoiding daytime naps improves nighttime sleep hygiene, a non-pharmacologic initial approach suitable for an elderly client.