Nokea
The nurse is caring for a client with a history of schizophrenia who is experiencing auditory hallucinations. Which of the following interventions should the nurse implement?
- A. Argue with the client about the reality of the voices.
- B. Encourage the client to listen to music with earphones.
- C. Instruct the client to ignore the voices completely.
- D. Ask the client to describe the voices in detail.
Correct Answer: B
Rationale: listening to music can distract the client and reduce the intensity of auditory hallucinations
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All of the following are risk factors for sudden infant death syndrome (SIDS) EXCEPT
- A. low birth weight.
- B. placing the child on his back to sleep.
- C. young maternal age.
- D. maternal smoking during pregnancy.
Correct Answer: B
Rationale: Placing an infant on their back to sleep reduces SIDS risk. Low birth weight, young maternal age, and maternal smoking are known risk factors.
The nurse is caring for a client admitted with acute laryngotracheobronchitis (LTB). Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?
- A. Intravenous access supplies
- B. Emergency intubation equipment
- C. Intravenous fluid-administration pump
- D. Supplemental oxygen
Correct Answer: B
Rationale: Emergency intubation equipment is essential for LTB due to the risk of airway obstruction requiring immediate intervention.
A student in a cardiac unit is performing auscultation of a client's heart. The nurse recognizes that the student is performing pulmonic auscultation correctly when the stethoscope is placed:
- A. Between the apex and the sternum
- B. At the fifth intercostal space at the left midclavicular line
- C. At the second intercostal space, left of the sternum
- D. At the manubrium
Correct Answer: C
Rationale: The pulmonic area is auscultated at the second intercostal space, left of the sternum, where the pulmonary valve sounds are best heard.
The nurse is caring for a child with Down syndrome. Which characteristics are commonly found in the child with Down syndrome?
- A. Fragile bones, blue sclera, and brittle teeth
- B. Epicanthal folds, broad hands, and transpalmar creases
- C. Low posterior hairline, webbed neck, and short stature
- D. Developmental regression and cherry-red macula
Correct Answer: B
Rationale: Down syndrome is characterized by epicanthal folds, broad hands, and transpalmar creases.
The nurse working the organ transplant unit is caring for a client with a white blood cell count of 450. During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?
- A. Allow the client to keep the fruit
- B. Place the fruit next to the bed for easy access by the client
- C. Offer to wash the fruit for the client
- D. Ask the family members to take the fruit home
Correct Answer: D
Rationale: A white blood cell count of 450 indicates severe immunosuppression, so the fruit should be removed to prevent infection from potential contaminants.