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The nurse is planning care for an 11-year-old child with attention deficit hyperactivity disorder who is hospitalized for surgical treatment of a fractured femur. What is the priority nursing action?
- A. Create a structured and consistent environment with a daily schedule
- B. Give the child a written schedule of activities
- C. Provide a verbal explanation of what to expect during hospitalization
- D. Restrict visitors while the child is hospitalized
Correct Answer: A
Rationale: A structured environment (A) supports ADHD management by reducing overstimulation and providing predictability, critical for a hospitalized child. Written schedules (B) and verbal explanations (C) are secondary, and restricting visitors (D) is unnecessary.
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A client who is 2 days post-operative from an appendectomy requests medication for pain. The client's vital signs are as follows: pulse 96, respirations 30, BP 130/92. The nurse should:
- A. Ask whether the client is anxious.
- B. Give the pain medication.
- C. Check the dressing for bleeding.
- D. Recheck the client's vital signs.
Correct Answer: B
Rationale: Pain medication is appropriate for a post-op client with pain and stable vitals. Anxiety may contribute, but pain should be addressed first. Bleeding checks or rechecking vitals are unnecessary without specific indicators.
The nurse has taught the parents of a 6-year-old client with nephrotic syndrome. Which of the following statements by the parents would require follow-up?
- A. I will encourage my child to play with other children.
- B. I will monitor my child's urine for protein every day.
- C. I will provide a healthy diet without added salt for my child.
- D. I will report swelling or rapid weight gain to the health care provider.
Correct Answer: A
Rationale: Encouraging play with others (A) may expose the child to infections, risky in nephrotic syndrome due to immunosuppression. Monitoring urine (B), low-salt diet (C), and reporting swelling (D) are correct.
The home health nurse is providing long-term care to several clients. Which are examples of inappropriately crossing professional boundaries? Select all that apply.
- A. Accepting a birthday gift of a gold bracelet from a client
- B. Offering to pray together if a client so wishes
- C. Sending a sympathy card to family after a client dies
- D. Soliciting a wealthy client to invest in a company
- E. Staying after work hours and drinking wine with a client
Correct Answer: A,D,E
Rationale: Accepting expensive gifts (A), soliciting investments (D), and socializing with alcohol (E) violate professional boundaries. Offering to pray (B) is acceptable if client-initiated, and a sympathy card (C) is appropriate.
The nurse is caring for a pregnant woman with pregnancy induced hypertension (PIH) receiving magnesium sulfate intravenously. In assessing the client, it is noted that respirations are 12, pulse and blood pressure have dropped significantly, and 8 hour output is 200 ml. What should the nurse do first?
- A. Administer calcium gluconate
- B. Call the provider immediately
- C. Discontinue the magnesium sulfate
- D. Perform additional assessments
Correct Answer: C
Rationale: The assessments strongly suggest magnesium sulfate toxicity. The nurse must discontinue the IV immediately and take measures to ensure the safety of the client.
The nurse is caring for a client who was recently prescribed methadone for chronic, severe back pain. The client indicates taking extra tablets in the last 6 hours when the pain recurred. Which findings during discharge require the client to be monitored longer in the hospital setting? Select all that apply.
- A. Falls asleep when the nurse is talking
- B. Frequently scratches from pruritus
- C. Has third emesis since taking medication
- D. Monitor shows occasional premature ventricular contractions
- E. Pulse oximetry reading is 92%
Correct Answer: A,C,D
Rationale: Falling asleep (A), vomiting (C), and premature ventricular contractions (D) indicate possible methadone overdose or toxicity, requiring extended monitoring. Pruritus (B) is a common side effect, and 92% oxygen saturation (E) is not critical.