Nokea
The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate? Select all that apply.
- A. Apply a water-based lubricant to the enema tube before insertion
- B. Assist the client into left lateral position with right knee flexed
- C. Encourage the client to retain the enema for as long as possible
- D. Keep the enema solution refrigerated until ready to administer
- E. Stop the infusion briefly if the client reports abdominal cramping
Correct Answer: A,B,C,E
Rationale: Lubricating the tube (A), left lateral positioning (B), retaining the enema (C), and pausing for cramping (E) are correct for safe administration. Refrigerating the solution (D) is incorrect; it should be at body temperature.
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The nurse admits a 2 year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure?
- A. He has been taking long naps for a week.'
- B. He has had an ear infection for the past 2 days.'
- C. He has been eating more red meat lately.'
- D. He seems to be going to the bathroom more frequently.'
Correct Answer: B
Rationale: He has had an ear infection for the past 2 days.' Contributing factors to seizures in children include those such as age (more common in first 2 years), infections (late infancy and early childhood), fatigue, not eating properly and excessive fluid intake or fluid retention.
The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse?
- A. I think you or your partner needs to stay with the child while in the hospital.'
- B. Oh, that is expected, so I would just ignore the behavior.'
- C. Perhaps you could gradually leave for short periods.'
- D. You should leave quickly to minimize the child's distress.'
Correct Answer: C
Rationale: Gradually increasing the time of separation can help the child adjust to the mother's absence, reducing anxiety and screaming over time.
The nurse is caring for a client who has acute pericarditis. Which of the following findings would be a priority to follow up?
- A. chest pain that is worse with deep inspiration
- B. muffled heart tones and jugular venous distension
- C. pericardial friction rub auscultated at the left sternal border
- D. temperature of 100.7 F (38.2 C) and a nonproductive cough
Correct Answer: B
Rationale: Muffled heart tones and jugular venous distension (B) suggest pericardial effusion or tamponade, a life-threatening complication requiring urgent follow-up. Chest pain (A) and friction rub (C) are expected, and mild fever (D) is less urgent.
While assisting a client with AM care, the nurse notes small elevated skin lesions less than $0.5 \mathrm{cm}$ in diameter over the client's back. The nurse should describe the lesions as:
- A. Macules
- B. Plaques
- C. Wheals
- D. Papules
Correct Answer: D
Rationale: Papules are small, elevated skin lesions less than 0.5 cm in diameter, matching the description provided.
The nurse is reinforcing teaching to parents about childhood nutrition and feeding practices. The nurse recognizes that which snack is best for a toddler?
- A. 1/2 cup orange juice
- B. Dry, sweetened cereal
- C. Raw carrot sticks
- D. Slice of cheese
Correct Answer: D
Rationale: A slice of cheese (D) is a nutrient-dense, easy-to-chew snack suitable for a toddler, providing protein and calcium. Orange juice (A) is high in sugar, sweetened cereal (B) lacks nutritional value, and raw carrot sticks (C) pose a choking hazard.