Nokea
The nurse is caring for a 4-year-old child in the emergency department who has a 104 F (40 C) temperature, is obtunded, and has a positive Kernig's sign. The parents are refusing antibiotics and any treatment. The parents state that their religious belief is to trust in just prayer and believe the child will receive divine healing. What action does the nurse anticipate?
- A. Assisting the parents in signing Against Medical Advice (AMA) papers
- B. Discharging the child if parents have power of attorney papers
- C. Notifying the hospital administration about the situation
- D. Reassuring the parents that their decision will be respected under the principle of autonomy
Correct Answer: C
Rationale: A 4-year-old with suspected meningitis requires urgent treatment. Notifying administration (C) ensures legal and ethical intervention to protect the child. AMA (A), power of attorney (B), or respecting autonomy (D) are inappropriate for a minor.
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A client is to be discharged following the removal of a cataract on the right eye. The nurse should tell the client to:
- A. Wear the metal eye shield only during waking hours.
- B. Report any eye pain to the doctor immediately.
- C. Refrain from using a pillow under his head.
- D. Avoid wearing dark glasses inside.
Correct Answer: B
Rationale: Reporting eye pain immediately is critical as it may indicate complications like infection or increased intraocular pressure. The eye shield is typically worn at night or as directed. Using a pillow is not contraindicated. Dark glasses are often recommended to reduce glare.
The nurse is making assignments for the day's care. Which assignment should not be given to the nursing assistant?
- A. Emptying the Foley catheter bag
- B. Administering a Fleet's enema
- C. Measuring the oral intake
- D. Feeding a client with depression
Correct Answer: B
Rationale: Administering an enema requires nursing judgment and is outside a nursing assistant's scope. Other tasks are appropriate for a nursing assistant.
The nurse is reviewing discharge teaching for a client who had surgical repair of a retinal detachment. Which of the following instructions are appropriate for the nurse to include in the teaching? Select all that apply.
- A. Avoid rubbing or scratching the affected eye
- B. Avoid straining when having a bowel movement
- C. Expect occasional flashes of light during recovery
- D. Report any sudden pain to the health care provider
- E. Rest the eyes by refraining from reading and writing
Correct Answer: A, B, D
Rationale: Avoiding rubbing (A), straining (B), and reporting sudden pain (D) prevent complications. Flashes (C) are not expected and require reporting, and eye rest (E) is unnecessary unless specified.
The nurse is caring for a 3-month-old infant who has bacterial meningitis. Which of the following clinical findings support this diagnosis? Select all that apply.
- A. Depressed anterior fontanelle
- B. High-pitched cry
- C. Poor feeding
- D. Presence of the Babinski sign
- E. Vomiting
Correct Answer: B, C, E
Rationale: High-pitched cry (B), poor feeding (C), and vomiting (E) are signs of bacterial meningitis in infants. A depressed fontanelle (A) suggests dehydration, not meningitis, and Babinski sign (D) is normal in infants.
A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?
- A. Diffuse expiratory wheezing
- B. Loose, productive cough
- C. No relief from inhalant
- D. Fever and chills
Correct Answer: A
Rationale: In asthma, the airways are narrowed, creating difficulty getting air in. A wheezing sound results.