Nokea
The nurse is contributing to the plan of care for an 8-year-old client with autism spectrum disorder. Which of the following interventions should the nurse suggest including in the client's plan of care? Select all that apply.
- A. Establish a consistent schedule for providing care.
- B. Encourage the parents to be present when providing care.
- C. Assign the same staff members to care for the client when possible.
- D. Place the client in a private room with familiar belongings.
- E. Use therapeutic touch to comfort the client.
Correct Answer: A,B,C,D
Rationale: Consistency in schedule (A), parental presence (B), familiar staff (C), and a private room with familiar items (D) reduce anxiety in children with autism. Therapeutic touch (E) may be distressing due to sensory sensitivities.
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The client has been vomiting for several days. Which blood gas values is he likely to have?
- A. pH=7.32; CO2=60; HCO3=30
- B. pH=7.32; CO2=33; HCO3=18
- C. pH=7.54; CO2=28; HCO3=22
- D. pH=7.54; CO2=32; HCO3=34
Correct Answer: C
Rationale: Prolonged vomiting causes metabolic alkalosis (high pH, low CO2) due to loss of stomach acid, matching pH=7.54, CO2=28, HCO3=22.
Following a typanoplasty, the nurse should maintain the client in which position?
- A. Semi-Fowler's with the operative ear facing down
- B. Low Trendelenburg with the head in neutral position
- C. Flat with the head turned to the side with the operative ear facing up
- D. Supine with a small neck roll to allow for drainage
Correct Answer: C
Rationale: After tympanoplasty, the client should be positioned flat with the head turned to the side and the operative ear facing up to promote healing and prevent pressure on the surgical site. Answer A is incorrect because the operative ear should face up, not down. Answer B is incorrect because low Trendelenburg is not indicated. Answer D is incorrect because a neck roll may not ensure proper positioning of the operative ear.
The nurse is documenting the assessment of a client's peripheral pulses. The nurse palpates the top portion of the client's feet and notes that the right pulse is full and strong, and the left pulse is diminished but still palpable. Which of the following would be correct documentation to include in the client's medical record?
- A. Bilateral dorsalis pedis pulses palpable. Right pulse 3+, left pulse 1+.
- B. Bilateral dorsalis pedis pulses palpable. Right pulse 4+, left pulse 2+.
- C. Bilateral popliteal pulses palpable. Right foot > left foot.
- D. Bilateral posterior tibial pulses palpable. Right pulse 3+, left pulse 1+.
Correct Answer: A
Rationale: The dorsalis pedis pulse is palpated on the top of the foot. A 3+ pulse is full and strong, and 1+ is diminished but palpable, accurately reflecting the findings.
The nurse is caring for a client who experienced a sexual assault and has posttraumatic stress disorder. The client states, 'It is all my fault. I should not have accepted a drink from a stranger I met at a bar.' Which of the following responses would be most appropriate for the nurse to make?
- A. Those thoughts are not good for you. You should try to stop thinking about the assault.
- B. You have to stop blaming yourself for the assault so you can move on with your life.
- C. It may take time to overcome your thoughts and feelings related to the assault.
- D. You could not have anticipated the assault. You did not deserve or ask for it.
Correct Answer: D
Rationale: This response validates the client's feelings while gently correcting self-blame, reinforcing that the assault was not their fault and promoting a supportive therapeutic environment.
The nurse is auscultating a client's breath sounds and identifies rhonchi. The nurse should recognize that rhonchi is consistent with
- A. croup
- B. pleurisy
- C. bronchitis
- D. pneumothorax
Correct Answer: C
Rationale: Rhonchi are low-pitched, rattling sounds caused by mucus or fluid in larger airways, commonly associated with bronchitis.