Nokea
The parent of a child treated for injuries consistent with suspected child abuse has been told that a report will be made to Child Protective Services (CPS). The parent says angrily to the nurse, 'I don’t know why this is being reported. I told the health care provider (HCP) that it was an accident.' What is the best response by the nurse?
- A. A case worker from CPS will be visiting you in a few days. The case worker can explain it to you then
- B. Did you ask the HCP why it is being reported?
- C. Reporting your child’s injuries is required by law. It is for your child’s safety and protection
- D. Your explanation of your child’s injuries does not seem plausible
Correct Answer: C
Rationale: Explaining that reporting is legally mandated for child safety is factual and nonjudgmental. Deferring to CPS, questioning the parent, or doubting their explanation may escalate tension or avoid responsibility.
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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 performing a developmental assessment on a 12-month-old client. Which of the following findings are expected at this age? Select all that apply.
- A. Birth weight has tripled
- B. Cruises along furniture
- C. Kicks a ball
- D. Searches for hidden objects
- E. Speaks in two word phrases
Correct Answer: A,B,D
Rationale: By 12 months, infants typically triple birth weight, cruise along furniture, and search for hidden objects (object permanence). Kicking a ball and two-word phrases are expected at 18-24 months.
A 4-month-old infant is being treated for talipes equinovarus (clubfoot). The nurse should include which of the following in the priority teaching plan for the parents?
- A. Monitor respiratory rate
- B. Monitor intake and output every hour
- C. Assist the client to breathe into a paper bag
- D. Prepare to administer oxygen by mask
Correct Answer: C
Rationale: Assisting the client to breathe into a paper bag addresses hyperventilation caused by aspirin toxicity, which can lead to respiratory alkalosis in the initial stages.
Medication administration record
Allergies: None
Medications Time
Haloperidol: 5 mg PO, twice a day 0900, 2100
Hydrochlorothiazide: 25 mg PO, daily 0900
Omeprazole: 20 mg PO, daily 0900
Acetaminophen: 650 mg PO, PRN Every 6 hours
The nurse on the inpatient psychiatric unit is preparing to administer 9 AM medications to a client. On assessment, the client is exhibiting signs of neuroleptic malignant syndrome. Which of the following actions should the nurse take?
- A. Administer acetaminophen, hold the haloperidol and reassess in 30 minutes
- B. Administer all medications, including acetaminophen, and reassess in 30 minutes
- C. Hold the haloperidol and notify the health care provider (HCP) immediately
- D. Hold the hydroxyzine and notify the HCP immediately
Correct Answer: C
Rationale: Neuroleptic malignant syndrome is a life-threatening reaction to antipsychotics like haloperidol, requiring immediate cessation and provider notification. Acetaminophen, continuing medications, or holding hydroxyzine do not address the emergency.
The nurse is caring for a client who had a total abdominal hysterectomy 2 days ago. The client reports hearing music coming from the television, which is turned off. Which of the following actions should the nurse take first?
- A. Ask the client when the auditory hallucinations began
- B. Check the client’s medication administration record
- C. Obtain a set of vital signs including temperature
- D. Turn on the television to see if the music stops
Correct Answer: B
Rationale: Checking the medication record identifies potential causes of hallucinations, such as opioids or anesthetics. Timing, vital signs, and TV checks are secondary to ruling out medication effects.