Nokea
The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A.
- A. Which observation indicates appropriate care for an 18-month-old with hepatitis A?
- B. The child is placed in a private room.
- C. The staff removes a toy from the child’s bed and takes it to the nurse’s station.
- D. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack.
- E. The staff uses standard precautions.
Correct Answer: A
Rationale: Hepatitis A requires contact precautions for diapered or incontinent patients, including a private room to prevent transmission. Removing toys risks spreading contamination, high-fat snacks are inappropriate, and standard precautions alone are insufficient.
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A nine-year-old client with an ostomy.
Which of the following statements, if made by the parents of a nine-year-old client with an ostomy, would indicate to the nurse that they are providing quality home care?
- A. We change the bag at least once a week, and we carefully inspect the stoma at that time.'
- B. We change the bag every day so that we can inspect the stoma and the skin.'
- C. We encourage our daughter to watch TV while we change her ostomy bag.'
- D. We only have to change the ostomy bag every ten days.'
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-ostomy bags should be changed at least once a week; good time for stoma to be closely inspected (2) bag should be changed at least once a week or when seal around stoma is loose or leaking (3) does not encourage client participation or foster independence (4) bag should be changed more often
The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client finding calls for immediate nursing action?
- A. Diaphoresis and shakiness
- B. Reduced lower leg sensation
- C. Intense thirst and hunger
- D. Painful hematoma on thigh
Correct Answer: A
Rationale: Diaphoresis and shakiness. Diaphoresis is a sign of hypoglycemia, which warrants immediate attention to prevent severe complications.
An 85-year-old woman recovering from a fractured pelvis in a long-term care facility. The woman's activity order reads: ambulate with walker bid.
After the nurse implements the order, which of the following charting entries is BEST?
- A. Patient ambulated well with walker. States has no c/o stiffness or pain. Did not appear fatigued.'
- B. Ambulated without difficulty for 20 minutes. Vital signs remained stable. Color good.'
- C. Walked full length of hall with walker. No difficulty with balance. Using walker correctly.'
- D. Patient ambulated 60 feet independently with walker. Gait steady. Respirations 14 and unlabored.'
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) gives subjective information (2) gives judgments without objective information (3) information is not complete, contains some judgments without objective information (4) correct-gives objective information
The nurse is teaching a client with a new diagnosis of type 2 diabetes about insulin detemir (Levemir). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this insulin at bedtime.
- B. I should rotate injection sites.
- C. I should refrigerate unopened vials.
- D. I should take this insulin when my blood sugar is high.
Correct Answer: D
Rationale: Taking insulin detemir when blood sugar is high is incorrect, as it is a long-acting basal insulin for steady control, not for acute hyperglycemia. Options A, B, and C are correct: bedtime dosing is standard, rotation prevents lipodystrophy, and refrigeration preserves insulin.
A client describing seeing snakes on the walls of his room in a psychiatric facility.
Based on this information, the nurse should identify a nursing diagnosis of
- A. sensory-perceptual alterations: visual.
- B. altered thought processes.
- C. ineffective individual coping.
- D. impaired social interaction.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-reflects a pattern of impaired perception, which is supported by the data that client is having a hallucination, defined as a sensory perception for which no external stimuli exist (2) not relevant to the data (3) not relevant to the data (4) not relevant to the data