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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A laboring woman has been pushing for one hour and is not making progress. The nurse knows that which of the following could hinder the descent of the fetus in the second stage of labor?
- A. A full bladder
- B. Paracervical block given during the first stage of labor
- C. Mother placed in a side-lying position
- D. Fetus in LOA (left occiput anterior) position
Correct Answer: A
Rationale: A full bladder obstructs fetal descent by occupying pelvic space, hindering labor progress, unlike anesthesia, positioning, or optimal fetal position.
At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states 'My blood pressure is usually much lower.' The nurse should tell the client to
- A. go get a blood pressure check within the next 48 to 72 hours
- B. check blood pressure again in 2 months
- C. see the health care provider immediately
- D. visit the health care provider within 1 week for a BP check
Correct Answer: A
Rationale: The blood pressure reading is moderately high with the need to have it rechecked in a few days. Although the client states it is 'usually much lower,' a concern exists for complications such as stroke. An immediate check by the provider of care is not warranted. Waiting 2 months or a week for follow-up is too long.
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.
The nurse is reinforcing teaching to a client with a history of diverticulitis about lifestyle changes the client should make to reduce the risk of future episodes. Which information should the nurse reinforce to reduce the risk of future episodes? Select all that apply.
- A. Drink plenty of fluids
- B. Exercise regularly
- C. Follow a low-fiber diet
- D. Increase whole grains, fruits, and vegetables in the diet
- E. Increase intake of red meat
Correct Answer: A,B,D
Rationale: Fluids, exercise, and high-fiber foods (whole grains, fruits, vegetables) prevent constipation and reduce diverticulitis risk. Low-fiber diets and red meat increase risk by promoting constipation and inflammation.
A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take?
- A. Have the client remove the existing dressing while the nurse prepares sterile supplies
- B. Wear clean gloves for removal and application of a new dressing
- C. Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing
- D. Wear sterile gloves, gown, and goggles to remove the soiled existing dressing
Correct Answer: C
Rationale: Clean gloves for removing soiled dressings prevent contamination, while sterile gloves for applying the new dressing maintain a sterile field. Full PPE is excessive for removal, and clean gloves for application risk infection.