Nokea
The nurse is teaching the parent of a 6-year-old client about sleep. Which of the following information should the nurse include? Select all that apply.
- A. Your child should sleep 9 to 12 hours every night.
- B. As your child grows, the hours of required sleep increase.
- C. Encourage active play before bedtime to promote restful sleep.
- D. Avoid giving your child large amounts of liquid after dinnertime.
- E. It is important to establish and maintain a regular bedtime routine.
Correct Answer: A,D,E
Rationale: Children aged 6 need 9-11 hours of sleep, limited liquids prevent bedwetting, and routines promote sleep. Sleep needs decrease with age, and active play close to bedtime may disrupt sleep.
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Following a stroke, an elderly client develops ptosis. When assessing the client, the nurse will note:
- A. Drooping of the eyelid on the affected side
- B. Inverted eyelid margins
- C. Eversion of eyelid margins
- D. Granulomatous inflammation of the eyelids
Correct Answer: A
Rationale: Ptosis or drooping of the eyelid can occur as the result of a stroke or Bell's palsy. Answer B refers to entropion, and answer C refers to ectropion, so they are incorrect. Answer D refers to chalazion, so it's incorrect. Answers B, C, and D are incorrect because they do not relate to ptosis.
A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the provider ordering
- A. pulmonary embolectomy
- B. vena caval interruption
- C. increasing the Coumadin therapy to an INR of 3-4
- D. thrombolytic therapy
Correct Answer: B
Rationale: vena caval interruption. Clients with contraindications to Heparin, recurrent PE or those with complications related to the medical therapy may require vena caval interruption by the placement of a filter device in the inferior vena cava. A filter can be placed transvenously to trap clots before they travel to the pulmonary circulation.
An adult is admitted with advanced cancer of the GI tract. What question must be included in the admission assessment?
- A. What foods do you like best?
- B. Do you have advance directives?
- C. Do you want CPR if you go into cardiac arrest?
- D. Do you understand the serious nature of your illness?
Correct Answer: B
Rationale: Advanced cancer requires discussion of end-of-life preferences. Asking about advance directives ensures the client's wishes are documented, taking priority over dietary preferences, specific CPR desires, or illness understanding.
A female client is admitted for a breast biopsy. She says, tearfully to the nurse, 'If this turns out to be cancer and I have to have my breast removed, my partner will never come near me.' The nurse's best response would be which of these statements?
- A. I hear you saying that you have a fear for the loss of love.'
- B. You sound concerned that your partner will reject you.'
- C. Are you wondering about the effects on your sexuality?'
- D. Are you worried that the surgery will lead to changes?'
Correct Answer: D
Rationale: This is a general lead-in type of response that encourages further discussion without focusing on an area that the nurse, but possibly not the client, feels is a problem.
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.