Nokea
The nurse is planning care for an 8 year-old child. Which of the following should be included in the plan of care?
- A. Encourage child to engage in activities in the playroom
- B. Promote independence in activities of daily living
- C. Talk with the child and allow him to express his opinions
- D. Provide frequent reassurance and cuddling
Correct Answer: A
Rationale: Encourage child to engage in activities in the playroom. According to Erikson, the school age child is in the stage of industry versus inferiority. To help them achieve industry, the nurse should encourage them to carry out tasks and activities in their room or in the playroom.
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The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct?
- A. May drink as much milk as desired
- B. Can have milk mixed with other foods
- C. Will benefit from fat-free cow's milk
- D. Should be limited to 3-4 cups of milk daily
Correct Answer: D
Rationale: Should be limited to 3-4 cups of milk daily. Excessive milk intake can reduce consumption of other nutrients.
The nurse is preparing a client environment that will reduce the chance of falls. Which action is appropriate?
- A. Keep the half side rails down on the side the client uses to get out of bed.
- B. Keep the lights down since glare bothers some clients.
- C. Call housekeeping to clean up the spilled water.
- D. Make sure that a path is cleared to assist the client when walking.
Correct Answer: D
Rationale: Clearing a path reduces tripping hazards, a key environmental modification to prevent falls.
A school-aged child informs the school nurse that his right knee 'doesn't feel right.' Which of the following actions should the nurse take FIRST?
- A. Instruct the child to extend the right leg.
- B. Put both of the child's legs through range-of-motion.
- C. Advise the child to soak the right knee in warm water.
- D. Compare the appearance of the right knee with the left knee.
Correct Answer: D
Rationale: Comparing knees assesses for swelling or deformity, the first step in physical assessment. Options A, B, and C risk exacerbating injury or are interventions before assessment.
A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure
- A. right heart function
- B. left heart function
- C. renal tubule function
- D. carotid artery function
Correct Answer: B
Rationale: left heart function. The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. It can provide hemodynamic information such as intracardiac pressure readings and oxygen saturation data, and even transvenous pacing. Information about left ventricular function is important because it directly affects tissue perfusion. Right-sided heart function is assessed through the evaluation of the central venous pressure (CVP).
The nurse is providing home care to a postoperative client who has a wound infection. What is essential to include when teaching the family about infection transmission?
- A. The client should stay isolated from the rest of the family.
- B. No one who is pregnant should care for the client.
- C. The family should wash hands before and after caring for the client.
- D. The client should not be allowed to have any visitors.
Correct Answer: C
Rationale: Hand washing before and after care is critical to prevent infection transmission. Isolation, restricting pregnant caregivers, or banning visitors are not necessary unless specified.