Nokea
The nurse prepares a 7-year-old client for an influenza injection. The nurse explains that the client will receive 'medicine under the skin,' and the client is visibly anxious. Which nursing intervention is appropriate?
- A. Ask the child to count to 10 during injection
- B. Ask the parent to hold the child's arms tightly
- C. Explain to the child that the injection will not hurt
- D. Keep the injection needle out of the child's view
Correct Answer: D
Rationale: Hiding the needle (D) reduces anxiety. Counting (A) may not distract enough, holding arms (B) can increase fear, and denying pain (C) is dishonest.
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The parents of a 4-year-old tell the nurse that the child won't go to sleep at night due to fear of tigers living under the bed. Which response by the nurse is most helpful?
- A. Have you recently visited the zoo? Maybe the tigers looked scary.
- B. If you agree with your child, the fears could continue through this developmental stage.
- C. Night fears are common at this age. Look under the bed with your child.
- D. This is very unusual. Maybe the child saw something scary on TV.
Correct Answer: C
Rationale: Night fears are normal in preschoolers (C). Checking under the bed with the child validates their fear while showing safety. Linking to a zoo visit (A) or media (D) assumes unconfirmed triggers. Agreeing with fears (B) may reinforce them.
A 56-year-old client who had a complete hysterectomy 8 months ago is admitted for opiate detoxification. The second day after admission, the client complains of abdominal cramping and sweating. What is the nurse's best response?
- A. Contact the gynecologist for details of the operation
- B. Suspect drug seeking and suggest the client take a walk around the unit
- C. Tell the client she is probably constipated and ask for an order for Milk of Magnesia
- D. Explain to the client that her symptoms are an expected physical response to detoxification and offer comfort medications as ordered
Correct Answer: D
Rationale: Abdominal cramping and sweating are withdrawal symptoms during opiate detoxification, requiring comfort measures and reassurance.
The nurse is teaching a client newly diagnosed with asthma how to use the metered-dose inhaler (MDI). The client asks when they will know the canister is empty. The best response is
- A. Drop the canister in water to observe floating
- B. Estimate how many doses are usually in the canister
- C. Count the number of doses as the inhaler is used
- D. Shake the canister to detect any fluid movement
Correct Answer: A
Rationale: Dropping the canister into a bowl of water assesses the amount of medication remaining in a metered-dose inhaler. The client should obtain a refill when the inhaler rises to the surface and begins to tip over.
The nurse is providing home care to an elderly woman who had a cerebrovascular accident several weeks ago. All of the following need to be done. Which should the nurse plan to do first?
- A. Auscultate lung fields
- B. Hygienic care
- C. Assist with ambulation
- D. Range-of-motion (ROM) exercises
Correct Answer: A
Rationale: Auscultating lung fields assesses respiratory status, a priority post-CVA to detect complications like pneumonia or atelectasis. Hygienic care, ambulation, and ROM are secondary.
The home health nurse is reinforcing teaching for a client with atrial fibrillation who is prescribed digoxin 0.25 mg orally on even-numbered days. Which client statement will require further teaching about digoxin?
- A. I will call the health care provider if I don't feel like eating.
- B. I will call the health care provider if I feel dizzy and lightheaded.
- C. I will call the health care provider if I have trouble reading.
- D. I will take my blood pressure before taking my medicine.
Correct Answer: D
Rationale: Taking blood pressure (D) is unrelated to digoxin monitoring. Anorexia (A Anorexia (A), dizziness (B), and visual changes (C) are signs of digoxin toxicity, requiring provider notification.