Nokea
The nurse is reviewing the plan of care for a 4-year-old client who will receive daily dressing changes for an infected leg wound. Which of the following interventions should the nurse include in the plan of care for a preschool-age child? Select all that apply.
- A. Allow the child's parents to stay during the procedure
- B. Emphasize that dressing changes are not punishment for misbehavior
- C. Encourage the child to voice questions and concerns about the procedure
- D. Have the child place bandages on a doll when reinforcing education
- E. Introduce the child to other clients with the same health condition
Correct Answer: A,B,C,D
Rationale: Parental presence provides comfort, clarifying that procedures are not punishment reduces fear, encouraging questions fosters understanding, and bandaging a doll makes the process relatable. Introducing the child to others with the same condition may breach privacy or cause distress.
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A 10-year-old weighs 99 lb (44.9 kg) and has a BMI of 24.8 kg/m² (>95th percentile). The licensed practical nurse (LPN) is collaborating with the registered nurse (RN) to formulate a weight loss plan. Which is most important for the nurse to determine?
- A. Child's pattern of daily physical activity
- B. Family's eating habits
- C. Family's financial resources for purchasing healthy foods
- D. Family's readiness for change
Correct Answer: D
Rationale: The family's readiness for change is critical, as it determines their willingness to adopt and sustain lifestyle changes necessary for weight loss. While activity, eating habits, and finances are important, motivation drives success.
The 24-hour day-night cycle is known as:
- A. circadian rhythm.
- B. infradian rhythm.
- C. ultradian rhythm.
- D. non-REM rhythm.
Correct Answer: A
Rationale: The circadian rhythm governs the 24-hour day-night cycle, regulating sleep and other physiological processes. The other terms refer to different biological rhythms. Basic Care and Comfort
The nurse has been assigned a client who is thought to be suicidal. All of the following are in the client's room. Which is safe to leave in the room?
- A. Paper cup
- B. Leather belt
- C. Razor
- D. Pillow
Correct Answer: A
Rationale: A paper cup poses no suicide risk. Belts, razors, and pillows (potential suffocation) are unsafe in a suicidal client's room.
Which of the following are correct nursing actions related to client positioning? Select all that apply.
- A. Position client in Fowler position after cardiac catheterization via femoral entry
- B. Position client in Trendelenburg position on the left side if air embolism is suspected
- C. Position client on the left side following a liver biopsy
- D. Position client on the side with head, back, and knees flexed during lumbar puncture
- E. Position client with the arm raised above the head for chest tube placement
Correct Answer: B,D,E
Rationale: Trendelenburg on the left traps air in the heart’s apex for air embolism, side-lying with flexion aids lumbar puncture access, and arm elevation facilitates chest tube placement. Fowler post-catheterization risks bleeding, and right side-lying is standard post-liver biopsy.
An elderly female is admitted with a fractured right femoral neck. Which assessment finding is expected?
- A. Free movement of the right leg
- B. Abduction of the right leg
- C. Internal rotation of the right hip
- D. Shortening of the right leg
Correct Answer: D
Rationale: The symptoms of this fracture include shortened, adducted, and external rotation. Answer A is incorrect because the patient usually is unable to move the leg due to pain. Answer B is incorrect because the symptom is adduction, not abduction. Answer C is wrong because it's external rotation, not internal rotation.