Nokea
The nurse is talking with the parent of an adolescent client who arrived at the emergency department after discovering that the client was involved in a motor vehicle collision. The parent asks about the clients condition. The client is unconscious and is currently receiving CPR. Which of the following responses would be appropriate for the nurse to make?
- A. I do not have any information about your child's condition, but you can see your child now.
- B. Your child is critically ill, and we are currently caring for your child's needs.
- C. The health care team is currently attempting to revive your child after your child's heart stopped.
- D. Only the health care provider is allowed to discuss your child's condition with you.
Correct Answer: C
Rationale: Honest, clear communication about the critical situation (CPR) is appropriate while maintaining sensitivity.
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In addition to disturbances in mental awareness and orientation, a client with cognitive impairment is also likely to show loss of ability in
- A. Hearing, speech, and sight
- B. Endurance, strength, and mobility
- C. Learning, creativity, and judgment
- D. Balance, flexibility, and coordination
Correct Answer: C
Rationale: Learning, creativity, and judgment. Cognitive impairments are due to physiological processes that affect memory and other higher-level cognitive processes.
The nurse is caring for a newborn with jaundice who is being treated with phototherapy. What action by the nurse would require the charge nurse to intervene?
- A. Allowing the parents to feed the newborn
- B. Applying a shirt while the client is exposed to phototherapy
- C. Covering the client's eyes with protective shields
- D. Monitoring the temperature of the incubator while the newborn is inside
Correct Answer: B
Rationale: Clothing during phototherapy reduces skin exposure to light, decreasing treatment efficacy.
The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR. The nurse receives and attaches an automated external defibrillator, but no shock is advised. Which action should the nurse perform next?
- A. Check for a carotid pulse for at least 10 seconds
- B. Provide rescue breaths at a rate of 10-12/min
- C. Resume chest compressions at a rate of 100/min
- D. Use the jaw-thrust maneuver to assess the airway
Correct Answer: C
Rationale: If no shock is advised, CPR should resume immediately with chest compressions to restore circulation.
A behavior modification program is planned for an adolescent who exhibits disruptive behavior. Which action by the nurse is most consistent with a behavior modification program?
- A. Punish the client if she becomes disruptive.
- B. Give the client extra privileges when she is not disruptive for a day.
- C. Remind the client what she is supposed to do at regular intervals.
- D. Ask the client what she sees as good behavior.
Correct Answer: B
Rationale: Positive reinforcement (extra privileges for non-disruptive behavior) aligns with behavior modification, encouraging desired actions. Punishment, reminders, or asking perceptions are less effective.
A client is admitted to the recovery room following an exploratory laparotomy. Which medication should be kept nearby?
- A. Nitroprusside (Nipride)
- B. Naloxone hydrochloride (Narcan)
- C. Flumazenil (Romazicon)
- D. Diphenhydramine (Benadryl)
Correct Answer: B
Rationale: Naloxone (Narcan) should be kept nearby to reverse opioid-induced respiratory depression, common after surgery due to anesthesia or pain management. Nitroprusside , flumazenil , and diphenhydramine are less relevant.