Nokea
The nurse on a pediatric unit is caring for a 2-year-old client. Which of the following interventions are appropriate to reduce the distress of hospitalization on the child? Select all that apply.
- A. Encourage the parent to leave the child alone for short intervals
- B. Follow the child’s home sleep schedule and routine
- C. Integrate preferred snack foods into the child’s routine
- D. Point out body changes that may occur
- E. Provide various options when choosing toys
Correct Answer: B,C,E
Rationale: Maintaining sleep routines, offering preferred snacks, and providing toy choices reduce distress by promoting familiarity and autonomy. Leaving alone or discussing body changes may increase anxiety.
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The nurse is discussing activities to promote language development with the parent of a 2-year-old. Which statement by the parent requires follow-up?
- A. I have dress-up clothes set out for my child to play with.
- B. I read brightly-colored picture books with rhymes with my child
- C. I set out a basket of toy cars when other children come to play
- D. I will enroll my child to play on a soccer team
Correct Answer: D
Rationale: Enrolling a 2-year-old in soccer is premature, as it does not directly promote language development and is not age-appropriate. Reading rhyming books and facilitating peer play with toys support language skills.
The home health hospice nurse visits a client who is newly prescribed extended-release oxycodone 40 mg orally, scheduled every 12 hours to treat severe chronic cancer pain. Which information is most important to reinforce to the client’s caregiver?
- A. Administer the medication around the clock even if the client denies having pain
- B. Avoid administering with immediate-release opioids to prevent respiratory depression
- C. Change the dosage and frequency to 20 mg every 6 hours if breakthrough pain occurs
- D. Request a tapered dose from the health care provider if pain decreases to prevent tolerance
Correct Answer: A
Rationale: Around-the-clock dosing maintains pain control in cancer, preventing peaks and troughs. Combining with immediate-release opioids is common, dosage changes require provider orders, and tapering is less critical in terminal care.
The nurse talking with a client with polycythemia vera. Which of the following statements by the client would require follow-up?
- A. I will drink plenty of water every day
- B. I should take a low-dose aspirin every day
- C. I need to have blood removed periodically
- D. I will continue taking my daily multivitamin with iron
Correct Answer: D
Rationale: Iron supplements can worsen polycythemia vera by increasing red blood cell production. Hydration, aspirin, and phlebotomy are appropriate management strategies.
The nurse is caring for a client diagnosed with polycythemia vera. Which statement by the client requires immediate follow-up?
- A. I am trying to find makeup to cover my unattractive, ruddy facial complexion
- B. I massage my sore leg to help bring the swelling down
- C. I take low-dose aspirin to relieve my occasional headaches
- D. My skin itches so severely, and no lotion or cream seems to help
Correct Answer: B
Rationale: Massaging a sore, swollen leg risks dislodging a clot in polycythemia vera, which predisposes to thrombosis. Ruddy complexion, aspirin use, and itching are expected but less urgent.
A father suspected of child abuse tells the nurse, 'I shouldn't have grabbed him so hard. I had a really bad day at work and got all stressed out. The kid just wouldn't listen to me.' The defense mechanism used by the father is:
- A. Projection
- B. Displacement
- C. Undoing
- D. Compensation
Correct Answer: B
Rationale: Displacement involves redirecting emotions (stress from work) onto a less threatening target (child). Projection, undoing, and compensation do not apply.