Nokea
The nurse is conducting health assessments for school-age children. A characteristic behavior of a 7-year-old girl is that she:
- A. Likes to play only with other girls.
- B. Prefers to play with her sister.
- C. Prefers to play team games.
- D. Likes to play alone.
Correct Answer: C
Rationale: At 7 years, children typically enjoy social interaction and team games, reflecting their developmental stage of cooperative play.
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Which of the following impacts on the client's preferences in terms of hygiene routines and practices?
- A. Culture
- B. Locus of control
- C. Bodily surface area
- D. Diaphoresis
Correct Answer: A
Rationale: Culture significantly influences hygiene preferences, as beliefs and practices vary widely across cultural groups.
The nurse is caring for a client with a history of deep vein thrombosis who is prescribed enoxaparin (Lovenox). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild bruising.
- B. Bleeding gums.
- C. Headache.
- D. Nausea.
Correct Answer: B
Rationale: Bleeding gums indicate a potential bleeding complication with enoxaparin, requiring immediate reporting.
You are caring for a hospice client who is at the end of life. Based on this client's signs and symptoms, the client is comatose, dehydrated, free of pain, constipated, without distress and expected to die in a day or two. Which of the following is an appropriate client outcome or an appropriate intervention for this client?
- A. The client will be free of constipation
- B. The client will remain free of pain and distress
- C. The administration of an antiemetic to prevent vomiting and further dehydration
- D. The administration of an enema to correct the constipation
Correct Answer: B
Rationale: Given the client's comatose state and imminent death, the priority is to maintain comfort. Ensuring the client remains free of pain and distress is the most appropriate outcome, as aggressive interventions like enemas or antiemetics are less relevant in this context.
The nurse is teaching a client about the use of a peak flow meter for asthma management. The client should be instructed to:
- A. Use it only during an attack
- B. Record the highest of three readings
- C. Clean it with alcohol daily
- D. Use it before exercise only
Correct Answer: B
Rationale: Recording the highest of three peak flow readings provides the most accurate assessment of lung function for asthma monitoring.
A client with a paranoid personality disorder sees some clients laughing during a group activity and asks the nurse, 'Why are they laughing at me? I bet they're making fun of me.' Which of the following responses by the nurse is most appropriate?
- A. You shouldn't let yourself get so upset
- B. Don't worry about them. They don't mean any harm
- C. Look. They seem to be having fun
- D. They're laughing at a joke John told. They aren't laughing at you
Correct Answer: D
Rationale: Providing a factual explanation that the laughter is due to a joke addresses the client's paranoia directly and reassuringly, reducing misinterpretation. Other responses dismiss or minimize the client's feelings.