Nokea
The nurse is planning care for a client who chews the fingers constantly. Before applying mitten restraints, the nurse could try which of the following interventions? Select all that apply.
- A. Ask the client to rub lotion over the hands every day after bathing.
- B. Encourage physical activity, such as ambulation.
- C. Provide frequent contacts for communication and socialization.
- D. Provide family education.
- E. Encourage involvement of family and friends.
Correct Answer: A,B,C,E
Rationale: Non-restrictive interventions like applying lotion, encouraging physical activity, providing social interaction, and involving family can address the behavior's underlying causes, such as anxiety or sensory needs, while promoting client autonomy and engagement.
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A 4-year-old child is admitted with a tentative diagnosis of Kawasaki disease. Which of the following laboratory findings is most likely to be found in this child?
- A. Leukocytosis.
- B. Thrombocytopenia.
- C. Decreased sedimentation rate.
- D. Hypoalbuminemia.
Correct Answer: A
Rationale: Kawasaki disease is commonly associated with leukocytosis, reflecting the inflammatory process characteristic of the condition.
A client with acute myocardial infarction receives therapy with alteplase. Which finding indicates to the nurse that the client is experiencing a possible complication?
- A. Epistaxis
- B. Vomiting
- C. ECG changes
- D. Absent pedal pulses
Correct Answer: A
Rationale: Bleeding is an adverse effect of altepase therapy. The bleeding can be superficial or internal and can be spontaneous. None of the remaining options are side or adverse effects of altepase therapy.
The nurse should assess the child with nephrotic syndrome for which of the following? Select all that apply.
- A. Normal blood pressure.
- B. Generalized edema.
- C. Normal serum lipid levels.
- D. No red blood cells in the urine.
- E. Elevated streptococcal antibody titers.
Correct Answer: B,D
Rationale: Nephrotic syndrome is characterized by generalized edema and no red blood cells in the urine. Blood pressure may be elevated, serum lipids are typically high, and streptococcal antibodies are not typically associated.
A client has been prescribed metoclopramide on a long-term basis. A home care nurse calls the primary health care provider immediately if which side effect is noted in this client?
- A. Excitability
- B. Anxiety or irritability
- C. Uncontrolled rhythmic movements of the face or limbs
- D. Dry mouth not minimized by the use of sugar-free hard candy
Correct Answer: C
Rationale: Metoclopramide is a 'prokinetic' drug used to treat heartburn. If the client experiences tardive dyskinesia (rhythmic movements of the face or limbs), the nurse should withhold the medication and call the primary health care provider. These side effects may be irreversible. Excitability is not a side effect of this medication. Anxiety, irritability, and dry mouth are milder side effects that are not harmful to the client.
The nurse is caring for a client who has just undergone a cesarean section. Which of the following interventions is most important in the immediate postoperative period?
- A. Encouraging early ambulation.
- B. Administering oral fluids immediately.
- C. Monitoring for signs of infection.
- D. Applying heat to the incision site.
Correct Answer: A
Rationale: Encouraging early ambulation post-cesarean section prevents complications like deep vein thrombosis and promotes recovery.