Nokea
The nurse is interviewing a 5-year-old client who is reporting abdominal pain. Which of the following are effective strategies for communicating with the child? Select all that apply.
- A. Allow the child to describe the symptoms
- B. Ask closed-ended questions to obtain pertinent information
- C. Explain procedures to match the child's concrete thinking
- D. Interview the child separately from the parents
- E. Maintain an eye-level position when speaking with the child
Correct Answer: A,C,E
Rationale: Allowing the child to describe symptoms encourages open communication, and interviewing separately reduces parental influence, ensuring accurate reporting. Closed-ended questions may limit a young child’s ability to express complex symptoms.
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The nurse is talking with a client who has gastroesophageal reflux disease and has been receiving long-term therapy with esomeprazole. Which of the following questions would be most important for the nurse to ask?
- A. Have you sustained any bone fractures recently?
- B. Are you experiencing an improved quality of sleep?
- C. Have you been checking your blood pressure regularly?
- D. Are you able to manage stressors in your life effectively?
Correct Answer: A
Rationale: Long-term esomeprazole use increases fracture risk due to reduced calcium absorption, making this the most critical question. Sleep, blood pressure, and stress are less directly related to esomeprazole’s side effects.
Which of the following activities demonstrate safe client handling practices? Select all that apply.
- A. 1 person assisting a client who is 8 hours post hip replacement surgery with a position change
- B. 1 person using a gait belt while transferring a partial weight-bearing client from the bed to a chair
- C. 2 people repositioning a client who is comatose and has been on the left side for 2 hours
- D. 3 people pulling up in bed a client who weighs 331 lb (150 kg)
Correct Answer: B,C,D
Rationale: Using a gait belt, two people for a comatose client, and three for a heavy client ensure safety and prevent injury. One person for a recent hip replacement risks falls or dislocation due to limited mobility.
The nurse is preparing to instill dialysate for a client who is receiving peritoneal dialysis. It would be a priority for the nurse to
- A. place the client in the semi-Fowler position
- B. record the characteristics of the dialysate output
- C. use sterile technique when spiking and attaching the bag of dialysate
- D. ensure that the drainage collection bag is below the level of the abdomen
Correct Answer: C
Rationale: Sterile technique when spiking and attaching the dialysate bag prevents peritonitis, a life-threatening complication. Semi-Fowler positioning, recording output, and bag placement are important but secondary to infection prevention.
Which of the following drugs should the nurse anticipate administering to a client before they are to receive electroconvulsive therapy?
- A. Benzodiazepines
- B. Chlorpromazine (Thorazine)
- C. Succinylcholine (Anectine)
Correct Answer: C
Rationale: Succinylcholine (Anectine). Succinylcholine is given intravenously to promote skeletal muscle relaxation.
The nurse is performing a sterile dressing change for a client when a second client begins yelling for pain medication. Which of the following actions should the nurse take?
- A. Ask unlicensed assistive personnel (UAP) to take the second client’s vital signs and report back immediately
- B. Direct UAP to ask the second client to rate the pain on a 0-10 scale and report back immediately
- C. Inform UAP to tell the second client that the nurse will be there soon and complete the sterile dressing change
- D. Interrupt the dressing change to medicate the second client
Correct Answer: C
Rationale: Completing the sterile dressing change maintains sterility and infection control, while informing the UAP to reassure the second client ensures their needs are addressed promptly without compromising the first client’s care.