Nokea
The nurse is caring for a 5-year-old client with sickle cell disease who is experiencing an episode of acute pain. The client has shortness of breath, nausea with vomiting, and severe generalized body and joint pain. Which of the following findings requires immediate intervention?
- A. enlarged spleen on palpation
- B. hemoglobin level of 9.0 g/dL (90 g/L)
- C. bilateral swelling of the hands and feet
- D. pain rated as 8 on the Wong-Baker FACES Scale
Correct Answer: A
Rationale: An enlarged spleen may indicate splenic sequestration, a life-threatening complication requiring immediate intervention.
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The nurse is discussing management of nocturnal enuresis with the parent of a 10-year-old client who has had little response to behavioral interventions. The parent tells the nurse, 'My child wants to go to overnight camp in several months but is afraid of being teased by other children if an accident occurs.' Which of the following responses would be most appropriate for the nurse to make?
- A. The condition will be resolved by then if you are consistent with bedtime routines.
- B. We can ask your child's health care provider about trying a medication that may be helpful.
- C. You could offer to send disposable training pants for your child to wear if needed.
- D. You should consider sending your child to day camp instead of overnight camp.
Correct Answer: B
Rationale: Medications like desmopressin may help manage enuresis for events like camp, addressing the child's concerns.
A client with a history of renal calculi passes a stone made up of calcium oxalate. Which of the following diet instructions should be given to the client?
- A. Increase intake of meats, eggs, fish, plums, and cranberries.
- B. Avoid citrus fruits and juices.
- C. Avoid dark green, leafy vegetables.
- D. Increase intake of dairy products.
Correct Answer: C
Rationale: Dark green, leafy vegetables are high in oxalates, which contribute to calcium oxalate stones. Meats and dairy increase other stone types, and citrus juices are beneficial.
Which of the following is not considered one of the five rights of medication administration?
- A. client
- B. drug
- C. dose
- D. routine
Correct Answer: D
Rationale: Dose, client, drug, route and time are considered the five rights of medication.
The daughter of a 78-year-old woman asks the nurse why her mother is giving away some of her belongings to her children and grandchildren. What should the nurse include when responding?
- A. Older adults usually become more generous.
- B. It is normal for older adults to think about and prepare for their own death.
- C. Her mother probably does not trust her children to divide her things appropriately.
- D. Her mother is probably thinking about suicide.
Correct Answer: B
Rationale: Giving away belongings reflects preparation for death, a normal developmental task in older adults achieving ego integrity. Generosity, distrust, or suicide are less likely.
A behavior modification program is planned for an adolescent who exhibits disruptive behavior. Which action by the nurse is most consistent with a behavior modification program?
- A. Punish the client if she becomes disruptive.
- B. Give the client extra privileges when she is not disruptive for a day.
- C. Remind the client what she is supposed to do at regular intervals.
- D. Ask the client what she sees as good behavior.
Correct Answer: B
Rationale: Positive reinforcement (extra privileges for non-disruptive behavior) aligns with behavior modification, encouraging desired actions. Punishment, reminders, or asking perceptions are less effective.