Nokea
The nurse is providing care to a 9-year-old client who is awaiting surgery. Which intervention is developmentally appropriate for this client's plan of care?
- A. Discuss the procedure with the client using simple diagrams with correct anatomical terminology
- B. Explore the client's perception of how the surgery will positively affect their future
- C. Focus primarily on the client's feelings and concerns regarding surgical scar appearance
- D. Provide initial education about the procedure to the client immediately before it is performed
Correct Answer: A
Rationale: Using simple diagrams with correct terminology (A) is age-appropriate for a 9-year-old, aiding understanding. Future benefits (B) are abstract, scar concerns (C) are secondary, and last-minute education (D) increases anxiety.
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Which behavioral characteristic describes the domestic abuser?
- A. Alcoholic
- B. Over confident
- C. High tolerance for frustrations
- D. Low self-esteem
Correct Answer: D
Rationale: Low self-esteem. Batterers were usually physically or psychologically abused as children or have had experiences of parental violence. Batterers are also manipulative, and have a great need to exercise control or power over their partners.
A parent has numerous questions regarding normal growth and development of a 10 month-old infant. Which of the following parameters is of most concern to the nurse?
- A. 50% increase in birth weight
- B. Head circumference greater than chest
- C. Crying when the parents leave
- D. Able to stand up briefly in play pen
Correct Answer: A
Rationale: 50% increase in birth weight. Birth weight should double by 6 months, indicating potential growth issues that require further evaluation.
An 80-year-old client is prescribed codeine for a severe cough. The home health nurse is reinforcing instructions on how to prevent the common adverse effects associated with codeine. Which client statements indicate an understanding of how to prevent them? Select all that apply.
- A. I'll be sure to apply sunscreen if I go outside.
- B. I'll drink at least 8 glasses of water a day.
- C. I'll drink decaffeinated coffee so I can sleep at night.
- D. I'll sit on the side of my bed for a few minutes before getting up.
- E. I'll take my medicine with food.
Correct Answer: B,D,E
Rationale: Drinking water (B) prevents constipation, sitting before standing (D) avoids orthostatic hypotension, and taking with food (E) reduces nausea. Sunscreen (A) and decaf coffee (C) are unrelated to codeine effects.
The family of an 88-year-old woman who was admitted with severe dehydration says to the nurse, 'Why don't you just tie down her arms so she won't try to get out her IV?' What is the best response for the nurse to make?
- A. Ask the physician for an order to restrain the woman
- B. Explain to the family that restraints are not allowed in the hospital unless the doctor orders them
- C. Assess the client's mental status and safety needs
- D. Tell the family that they can restrain the client, but the nurse cannot
Correct Answer: C
Rationale: Assessing mental status and safety needs determines if restraints are necessary, prioritizing least restrictive measures.
A gravida para 1 reports that a prior pregnancy ended in loss of the baby early in the pregnancy. Which of the following instructions should be given to the client?
- A. She should refrain from sex during this pregnancy
- B. She should avoid stimulation of the breasts
- C. She should quit work until after the baby is born
- D. She should report any nausea and vomiting
Correct Answer: D
Rationale: Reporting nausea and vomiting is important, as severe symptoms could indicate complications like hyperemesis gravidarum, especially given the history of pregnancy loss.