Nokea
The nurse is caring for a preschool child who is being treated in the hospital for respiratory syncytial virus (RSV). In planning the client's care, the nurse should recognize that the child is likely to view this illness as?
- A. Punishment.
- B. Disturbance to body image.
- C. Rejection from parents.
- D. Change in routine with friends.
Correct Answer: A
Rationale: The correct answer is A: Punishment. Preschool children often see illness as a form of punishment, especially when they are unable to understand the cause of their sickness. This perception is rooted in their limited cognitive abilities and understanding of health concepts. Choices B, C, and D are incorrect because preschool children are less likely to associate illness with disturbance to body image, rejection from parents, or changes in routine with friends. These options are not developmentally appropriate for how preschoolers typically interpret illness.
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Which client should be seen first by the Emergency Department nurse?
- A. A six-year-old with a femur fracture.
- B. A two-year-old with a fever of 102 degrees F.
- C. A three-year-old with wheezes in the right lower lobe.
- D. A two-year-old whose gastrostomy tube came out.
Correct Answer: C
Rationale: The priority in the emergency department is to assess and manage clients based on the severity of their condition. In this scenario, the three-year-old with wheezes in the right lower lobe should be seen first because respiratory distress takes precedence over other conditions. Wheezing indicates potential airway compromise, which requires immediate attention to ensure adequate oxygenation. The other options are important but do not pose an immediate threat to the client's airway and breathing. A femur fracture, fever, or a dislodged gastrostomy tube can be addressed after ensuring the child with respiratory distress is stable.
A child with newly diagnosed leukemia is receiving chemotherapy. Which would be included in his plan of care by the nurse?
- A. Place the child in a negative pressure isolation room
- B. Administer prophylactic IV antibiotics
- C. Avoid high protein food intake
- D. Teach family and visitors handwashing techniques
Correct Answer: D
Rationale: The correct answer is to teach family and visitors handwashing techniques. Any client on chemotherapy should have good infection control measures in place, such as handwashing by all who they encounter. Placing the child in a negative pressure isolation room (Choice A) is not necessary unless specifically indicated for a certain condition. Administering prophylactic IV antibiotics (Choice B) may not be part of the standard care plan for a child with leukemia receiving chemotherapy. Avoiding high protein food intake (Choice C) is not directly related to infection control and may not be necessary unless there are specific dietary restrictions.
The nurse is preparing for a dressing change on a full thickness burn to the flank area. The orders include irrigating the wound with each dressing change. To irrigate the wound, what will the nurse use?
- A. Sterile saline
- B. Distilled water
- C. Betadine scrub
- D. Tap water
Correct Answer: A
Rationale: When irrigating a wound, especially in the case of a full-thickness burn, it is crucial to use a solution that is gentle and non-irritating to the tissues. Sterile saline is the preferred choice for wound irrigation as it is isotonic and does not cause additional damage to the already compromised tissue. Distilled water lacks the electrolytes present in saline, Betadine scrub is not used for irrigation due to its potential to be cytotoxic, and tap water may introduce contaminants and microorganisms to the wound.
The client with ulcerative colitis calls the clinic and reports increasing abdominal pain and increased frequency of loose stools. He asks to clarify what type of diet he is to follow. Which diet is best for clients with ulcerative colitis?
- A. High vitamin
- B. High calorie
- C. Low sugar
- D. Low fiber
Correct Answer: D
Rationale: The correct answer is 'Low fiber.' Clients with ulcerative colitis should follow a low-residue diet, which means consuming low fiber to reduce the frequency and volume of stools, helping to alleviate symptoms such as abdominal pain and diarrhea. High fiber diets can worsen the condition by stimulating bowel movements. Choice A, 'High vitamin,' is incorrect as the focus is on fiber content rather than vitamins. Choice B, 'High calorie,' is not specifically recommended for ulcerative colitis and may not address the symptoms effectively. Choice C, 'Low sugar,' does not directly address the dietary needs of clients with ulcerative colitis as the issue is more related to fiber intake than sugar consumption.
Which of the following goals is the most important for the nurse to address for a client admitted to the cardiac rehabilitation unit?
- A. Reduction of anxiety
- B. Referral to community resources
- C. Identification of lifestyle changes
- D. Verbalization of energy-conservation techniques
Correct Answer: C
Rationale: The most important goal for a client admitted to the cardiac rehabilitation unit is the identification of lifestyle changes. This is crucial in promoting cardiovascular health and preventing future cardiac issues. Lifestyle changes such as diet modifications, exercise routines, smoking cessation, and stress management play a significant role in improving the overall cardiovascular well-being of the patient. While reducing anxiety, referring to community resources, and verbalizing energy-conservation techniques are all important aspects of care, identifying lifestyle changes is the primary focus in helping the client achieve long-term cardiovascular wellness.