Nokea
The nurse is caring for a 4-year-old who was hospitalized with influenza. Which nursing action would be most effective to maintain psychosocial integrity?
- A. Encouraging use of puzzles for play
- B. Offering the child stacking blocks for diversion
- C. Providing crayons to draw noses on facemasks
- D. Suggesting that playmates visit the child
Correct Answer: C
Rationale: Drawing on facemasks is an age-appropriate, creative activity that promotes self-expression and reduces fear associated with medical equipment, supporting psychosocial integrity.
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The nurse enters a client's room and finds that the client and spouse are crying. The spouse states that the health care provider just diagnosed the client with Alzheimer disease. What is the best response by the nurse?
- A. Do you have any questions about the diagnosis?
- B. There are medications available to treat Alzheimer disease.
- C. This new diagnosis must be frightening for you.
- D. We can help you make decisions about your care.
Correct Answer: C
Rationale: Acknowledging the emotional impact of the diagnosis validates the client's and spouse's feelings, fostering therapeutic communication and trust.
A student nurse is caring for a client with iron deficiency anemia who is newly prescribed ferrous sulfate. Which action by the student nurse requires the supervising nurse to intervene?
- A. Encourages the client to drink extra fluids while taking ferrous sulfate
- B. Offers the client orange juice for administration of ferrous sulfate
- C. Plans to administer ferrous sulfate one hour before breakfast
- D. Prepares to administer a prescribed calcium supplement with ferrous sulfate
Correct Answer: D
Rationale: Calcium inhibits iron absorption, so administering ferrous sulfate with a calcium supplement reduces its effectiveness, requiring intervention.
The nurse is reinforcing teaching with an adolescent client who has acne vulgaris. Which of the following information should the nurse reinforce? Select all that apply.
- A. A well-balanced diet can help support healthy skin.
- B. Antibacterial soap is harsh and can make your acne worse.
- C. Scrub whiteheads vigorously when washing your face twice daily.
- D. Squeezing or picking the lesions may increase the risk for infection and scarring.
- E. Use skin care products labeled as noncomedogenic to avoid clogging your skin pores.
Correct Answer: A,B,D,E
Rationale: A balanced diet (A), avoiding harsh soaps (B), not picking lesions (D), and using noncomedogenic products (E) promote skin health and prevent acne exacerbation.
A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states, 'I refuse both radiation and chemotherapy because they are 'hot.' The next action for the nurse to take is to
- A. document the situation in the notes
- B. report the situation to the health care provider
- C. explain the client to the child's disease
- D. ask the client to talk about concerns regarding 'hot' treatments
Correct Answer: D
Rationale: ask the client to talk about concerns regarding 'hot' treatments. The 'hot-cold' system is found among Mexican-Americans, Puerto Ricans, and other Hispanic-Latinos. Most foods, beverages, herbs, and medicines are categorized as hot or cold, which are symbolic designations and do not necessarily indicate temperature or spiciness. Care and treatment regimens can be negotiated with clients within this framework.
The nurse is reinforcing teaching for a client who has a new prescription for levothyroxine. Which of the following information should the nurse reinforce?
- A. Discontinue the medication if you become pregnant.
- B. Take the medication at bedtime to decrease drowsiness.
- C. Notify your health care provider if you experience palpitations.
- D. Take the medication with a snack if you experience an upset stomach.
Correct Answer: C
Rationale: Palpitations may indicate levothyroxine overdose or hyperthyroidism, requiring prompt reporting to adjust the dose or evaluate thyroid function.