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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A pediatric client has been receiving Amoxil (amoxicillin) for acute otitis media. It is important the child receive all the medication. Which secondary disorder is associated with improper management of acute otitis media?
- A. Cholesteatoma
- B. Mastoiditis
- C. Acoustic neuroma
- D. Presbycusis
Correct Answer: B
Rationale: Improper management of acute otitis media can lead to mastoiditis, an infection of the mastoid bone that can result from untreated or inadequately treated ear infections. Answer A (cholesteatoma) is a possible complication but less directly associated with improper antibiotic management. Answer C (acoustic neuroma) is unrelated to otitis media. Answer D (presbycusis) is age-related hearing loss, not a complication of otitis media.
The nurse is reinforcing instructions about the use of regular and neutral protamine Hagedorn (NPH) insulin. Which statement by the client indicates that further instruction is needed?
- A. I will always check my blood glucose prior to using the sliding scale.
- B. I will eat breakfast 30 minutes after taking my morning NPH and regular insulin.
- C. I will use a new insulin syringe each time I give myself an injection.
- D. I will use the sliding scale to determine my NPH dose 4 times a day.
Correct Answer: B
Rationale: Eating 30 minutes after NPH and regular insulin (B) risks hypoglycemia, as regular insulin acts within 30 minutes. Checking glucose (A), using new syringes (C), and sliding scale for regular insulin (D) are correct.
A 31-year-old client is admitted to the psychiatric unit after cutting both wrists with a kitchen knife. The client has a diagnosis of borderline personality disorder. The most therapeutic approach by the nurse is one that is:
- A. Warm and nurturing
- B. Open and flexible
- C. Firm and consistent
- D. Nonintrusive and passive
Correct Answer: C
Rationale: A firm and consistent approach provides structure and boundaries, which are therapeutic for clients with borderline personality disorder who often test limits.
The nurse is observing a staff member collecting a sputum specimen from a client with active tuberculosis. The nurse should intervene if the staff member is observed
- A. leaving unused supplies in the client's room after the procedure
- B. putting on clean gloves before putting on a protective gown
- C. leaving a dedicated, disposable stethoscope in the client's room
- D. putting on an N95 respirator mask and face shield before entering the client's room
Correct Answer: A
Rationale: Leaving supplies (A) in a TB room risks contamination. Gloves before gown (B), dedicated stethoscope (C), and N95 with face shield (D) are appropriate.
The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse perform first?
- A. Explain that the procedure will help him to get well
- B. Show a cartoon character with a blood pressure cuff
- C. Explain that the blood pressure checks the heart pump
- D. Permit handling the equipment before putting the cuff in place
Correct Answer: D
Rationale: Permit handling the equipment before putting the cuff in place. The best way to gain the toddler's cooperation is to encourage handling the equipment. Detailed explanations are not helpful.