Nokea
The nurse on a pediatric unit is caring for a preschooler who exhibits separation anxiety when the parents go to work. Which interventions should the nurse implement? Select all that apply.
- A. Encourage the parents to leave the child's favorite stuffed animal
- B. Establish a daily schedule similar to the child's home routine
- C. Give the child time to calm down alone when visibly upset
- D. Provide frequent opportunities for play and activity
- E. Remove visual reminders of the parents from the room
Correct Answer: A,B,D
Rationale: To manage separation anxiety: a stuffed animal provides comfort, a familiar schedule offers stability, and play distracts and engages. Isolating the child may worsen anxiety, and removing parental reminders could increase distress.
You may also like to solve these questions
A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency?
- A. I am very tired, and it's hard for me to keep my eyes open.'
- B. I don't feel good, and I want to be seen.'
- C. I have not taken my blood pressure medicine in over a week.'
- D. I have the worst headache I've ever had in my life.'
Correct Answer: D
Rationale: A severe headache described as the worst ever with diplopia and nausea suggests a possible subarachnoid hemorrhage or aneurysm, requiring emergency evaluation. Other statements (A, B, C) are less specific.
The nurse is caring for a client with spontaneous rupture of membranes. The nurse notes a loop of umbilical cord protruding from the vagina. Which of the following actions should the nurse take?
- A. Apply suprapubic pressure
- B. Perform Leopold maneuvers
- C. Perform the McRoberts maneuver
- D. Assist the client to the knee-chest position
Correct Answer: D
Rationale: Umbilical cord prolapse is an emergency requiring the knee-chest position to relieve cord compression. Suprapubic pressure and McRoberts are for shoulder dystocia, and Leopold maneuvers are for fetal positioning assessment.
The nurse observes a nursing assistant caring for an 86-year-old woman who had an open reduction/internal fixation for a fractured femur two days ago. Which action by the nursing assistant needs correction by the nurse?
- A. The nursing assistant places an abductor pillow between the client's legs while turning the client.
- B. The nursing assistant asks the client to put full weight on both legs while using the walker.
- C. The nursing assistant has a high extended bedside commode available for the client.
- D. The nursing assistant encourages the client to bathe herself.
Correct Answer: B
Rationale: Full weight-bearing two days post-femur fixation is inappropriate, risking hardware failure; partial or non-weight-bearing is typical. Abductor pillows, commodes, and self-bathing are appropriate.
After passing a nasogastric (NG) tube in an adult, the nurse checks for proper placement by doing which of the following?
- A. Injecting air into the NG tube and listening with a stethoscope over the stomach for a 'swoosh'
- B. Putting the end of the NG tube in a glass of water and observing for bubbles
- C. Asking the client if the tube is comfortable
- D. Aspirating contents and checking the pH
Correct Answer: D
Rationale: Aspirating gastric contents and checking pH (typically 1-5 for stomach) is the most reliable method to confirm NG tube placement in the stomach. Air injection is less definitive, water bubbling is unsafe, and comfort does not confirm placement.
A client is experiencing an exacerbation of chronic lower back pain after working in the yard all weekend. The nurse should reinforce the primary importance of which nonpharmacologic intervention for acute muscle pain?
- A. Heating pad
- B. Positioning for comfort
- C. Rest from pain-aggravating activities
- D. Stretching exercises
Correct Answer: C
Rationale: For acute lower back pain, rest from aggravating activities is primary to prevent further strain. Heat and positioning are helpful but secondary, and stretching may worsen acute pain.