Nokea
The nurse is contributing to the plan of care for a client with pertussis. Which of the following interventions should the nurse suggest including in the client's plan of care? Select all that apply.
- A. Monitor the client's respiratory effort.
- B. Implement droplet precautions for the client.
- C. Place the client in a room with monitored negative air pressure.
- D. Request a prescription for a cough suppressant for the client.
- E. Offer the client small sips of fluid frequently.
Correct Answer: A, B, E
Rationale: Monitoring respiratory effort (A), droplet precautions (B), and frequent fluids (E) manage pertussis symptoms and transmission. Negative pressure rooms (C) are for airborne diseases, and cough suppressants (D) may worsen mucus clearance.
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The nurse in a long-term care facility is caring for a client with major depressive disorder who is reporting difficulty sleeping. The client gets up during the night, paces the hallway, wrings the hands, and appears teary. Which of the following actions should the nurse take? Select all that apply.
- A. Arrange for the client to receive at least 20 minutes of natural sunlight each day
- B. Encourage the client to take naps during the day
- C. Instruct the client to engage in physical exercise just before bedtime
- D. Provide the client with a cup of warm milk in the evening
- E. Spend time with the client in a quiet environment just before bedtime
- F. Suggest that the client listen to soft music before going to bed
Correct Answer: A, D, E, F
Rationale: Natural sunlight exposure (A) helps regulate circadian rhythms and improve mood. Warm milk (D) contains tryptophan, which promotes sleep. A quiet environment (E) and soft music (F) reduce stimulation and promote relaxation. Naps (B) may disrupt nighttime sleep, and exercise before bedtime (C) can be stimulating.
Vital signs
Temperature 95 F (35 C)
Blood pressure 90/50 mm Hg
Heart rate 50/min
Respirations 6/min
SpO2 83%
The nurse is caring for a client with hypothyroidism who has become lethargic and difficult to rouse. Which action is the priority?
- A. Administer scheduled PO levothyroxine
- B. Perform bag-valve-mask ventilation
- C. Place a warming blanket on the client
- D. Review client's thyroid laboratory results
Correct Answer: B
Rationale: Lethargy and unresponsiveness in hypothyroidism suggest myxedema coma, requiring immediate airway management with ventilation (B). Levothyroxine (A), warming (C), and lab review (D) are secondary.
Which statement by a parent would alert the nurse to assess for iron deficiency anemia in a 14 month-old child?
- A. I know there is a problem since my baby is always constipated.
- B. My child doesn't like many fruits and vegetables, but she really loves her milk.
- C. My child is not eating as much as she did 4 months ago.
- D. My child doesn't drink a whole glass of juice or water at 1 time.
Correct Answer: B
Rationale: My child doesn't like many fruits and vegetables, but she really loves her milk. Excessive milk intake can displace iron-rich foods, leading to iron deficiency anemia.
The nurse is discussing child safety with a group of mothers of toddlers. Which statement indicates a need for more instruction?
- A. My child should be in the back seat in a front-facing car seat.'
- B. My little one needs constant supervision.'
- C. My child eats finger foods.'
- D. I should put my medicines on a high shelf.'
Correct Answer: A
Rationale: Toddlers (under 2 years) should be in rear-facing car seats for safety; front-facing is incorrect, indicating a need for further instruction.
The client with hyperparathyroidism will exhibit signs of:
- A. Hypokalemia
- B. Hyponatremia
- C. Hypercalcemia
- D. Hyperphosphatemia
Correct Answer: C
Rationale: Hyperparathyroidism increases parathyroid hormone, causing hypercalcemia by mobilizing calcium from bones and increasing absorption. Hypokalemia , hyponatremia , and hyperphosphatemia are not typically associated.