Nokea
The nurse is preparing to administer ear drops to a 5-year-old client. Which of the following actions should the nurse take?
- A. Pull the client's pinna upward and back.
- B. Help the client sit upright with the chin tilted down.
- C. Touch the dropper to the entrance of the ear canal.
- D. Remove the medication from the refrigerator just before use.
Correct Answer: A
Rationale: Pulling the pinna upward and back (A) straightens the ear canal in children over 3. Sitting with chin down (B), touching the canal (C), or cold drops (D) are incorrect.
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The nurse in a long-term care facility is caring for a client with major depressive disorder who is reporting difficulty sleeping. The client gets up during the night, paces the hallway, wrings the hands, and appears teary. Which of the following actions should the nurse take? Select all that apply.
- A. Arrange for the client to receive at least 20 minutes of natural sunlight each day
- B. Encourage the client to take naps during the day
- C. Instruct the client to engage in physical exercise just before bedtime
- D. Provide the client with a cup of warm milk in the evening
- E. Spend time with the client in a quiet environment just before bedtime
- F. Suggest that the client listen to soft music before going to bed
Correct Answer: A, D, E, F
Rationale: Natural sunlight exposure (A) helps regulate circadian rhythms and improve mood. Warm milk (D) contains tryptophan, which promotes sleep. A quiet environment (E) and soft music (F) reduce stimulation and promote relaxation. Naps (B) may disrupt nighttime sleep, and exercise before bedtime (C) can be stimulating.
A client receiving aminophylline IV complains of feeling nervous and shaky. The nurse is aware that these are symptoms of:
- A. CNS depression that accompanies xanthine derivatives
- B. CNS stimulation that sometimes accompanies xanthine derivatives
- C. The anticholinergic effects of aminophylline
- D. Cardiovascular depression that can accompany xanthine derivatives
Correct Answer: B
Rationale: Aminophylline, a xanthine derivative, can cause CNS stimulation, leading to nervousness and shakiness. It does not typically cause CNS or cardiovascular depression or anticholinergic effects.
The nurse is reinforcing home care instructions to a client newly diagnosed with osteomalacia. Which of the following client statements indicate proper understanding of teaching? Select all that apply.
- A. I will avoid foods high in calcium and phosphorus.'
- B. I will avoid going outside on sunny days.'
- C. I will eat foods that are fortified with vitamin D.'
- D. I will engage in physical activity to increase bone strength.'
- E. I will use a cane to help me get around better.'
Correct Answer: C, D
Rationale: Vitamin D-rich foods (C) and physical activity (D) improve bone health in osteomalacia. Avoiding calcium/phosphorus (A), sunlight (B), or using a cane (E) are incorrect or unnecessary.
The nurse is caring for a client who had a colostomy. Which comment by the client indicates that she is showing an interest in learning about her colostomy?
- A. Why did this problem have to happen to me?'
- B. What is the bag of water for?'
- C. When will I get rid of this thing?'
- D. The doctor didn't really do a colostomy.'
Correct Answer: B
Rationale: Asking about the bag's purpose shows curiosity and readiness to learn about colostomy care. Other comments reflect denial, frustration, or lack of engagement.
The nurse caring for a 2-year-old client should expect the child to be able to perform which of the following actions? Select all that apply.
- A. Draw a square
- B. Hop on one foot
- C. Kick a large ball
- D. Use 2-word phrases
- E. Walk without help
Correct Answer: C, D, E
Rationale: A 2-year-old can kick a ball (C), use 2-word phrases (D), and walk without help (E). Drawing a square (A) and hopping on one foot (B) are skills typically developed later.