Nokea
The nurse is caring for a school-aged client recently diagnosed with attention deficit hyperactivity disorder. The nurse should recognize that the client is at risk for experiencing
- A. delayed physical development
- B. delusions
- C. low self-esteem
- D. Paranoia
Correct Answer: C
Rationale: Children with ADHD often face challenges with academic performance and social interactions, increasing the risk of low self-esteem. A is not typically associated with ADHD. B and D are more relevant to psychotic disorders, not ADHD.
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The nurse is caring for a 6-month-old client who has a new tracheostomy. Which of the following findings would indicate that the client's airway requires suctioning? Select all that apply.
- A. Audible gurgling
- B. Heart rate of 110/min
- C. Increased irritability
- D. Oxygen saturation of 88%
- E. Respiratory rate of 30/min
Correct Answer: A,C,D
Rationale: Audible gurgling, irritability, and low oxygen saturation (88%) indicate airway obstruction or secretions requiring suctioning. Normal heart rate (110/min) and respiratory rate (30/min) for a 6-month-old do not necessitate suctioning.
The parent of an 8-year-old client asks the nurse for guidance on how to help the client cope with the recent death of the other parent. When developing a response to the parent, the nurse considers that a school-aged child is most likely to do what?
- A. React anxiously to altered daily routines
- B. Realize that death eventually affects everyone
- C. Think about the religious or spiritual aspects of death
- D. Understand that death is permanent but be curious about it
Correct Answer: D
Rationale: School-aged children (around 8 years old) typically understand death's permanence and may exhibit curiosity about it, which can guide coping strategies. A is more common in younger children. B and C are more typical of adolescents, who have more abstract thinking.
On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse's initial response should be to
- A. Give the client orientation materials and review the unit rules and regulations
- B. Introduce him/herself and accompany the client to the client's room
- C. Take the client to the day room and introduce her to the other clients
- D. Ask the nursing assistant to get the client's vital signs and complete the admission search
Correct Answer: B
Rationale: Introduce him/herself and accompany the client to the client's room. This reduces anxiety by providing a calm and secure environment.
The mother of a newborn child is very upset. The child has a cleft lip and palate. The type of crisis this mother is experiencing is:
- A. reactive.
- B. maturational.
- C. situational.
- D. adventitious.
Correct Answer: C
Rationale: The arrival of the imperfect child that the mother had not envisioned places the mother in a situational crisis.
The nurse is teaching an elderly client how to use MDIs (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse's best recommendation to improve delivery of the medication?
- A. Nebulized treatments for home care
- B. Adding a spacer device to the MDI canister
- C. Asking a family member to assist the client with the MDI
- D. Request a visiting nurse to follow the client at home
Correct Answer: B
Rationale: If the client is not using the MDI properly, the medication can get trapped in the upper airway, resulting in dry mouth and throat irritation. Using a spacer will allow more drug to be deposited in the lungs and less in the mouth.