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The parents of a 2-year-old child are ready to begin toilet training activities with him. His parents feel he is ready to train because he is now 2 years old. What would the nurse identify as readiness in this child?
- A. Patience by the child when wearing soiled diapers
- B. Communicating the urge to defecate or urinate
- C. The child awakening wet from his naps
- D. The age at which the child's siblings were trained
Correct Answer: B
Rationale: A child must be able to use verbal or nonverbal skills to communicate needs, indicating readiness for toilet training.
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A 42-year-old client with bipolar disorder has been hospitalized on the inpatient psychiatric unit. She is dancing around, talking incessantly, and singing. Much of the time the client is anorexic and eats very little from her tray before she is up and about again. The nurse's intervention would be to:
- A. Confront the client with the fact that she will have to eat more from her tray to sustain her
- B. Try to get the client to focus on her eating by offering a detailed discussion on the importance of nutrition
- C. Let her have snacks and drinks anytime that she wants them because she will not eat at regular meal times
- D. Not expect the client to sit down for complete meals; monitor intake, offering snacks and juice frequently
Correct Answer: D
Rationale: The manic client's mood may easily change from euphoric to irritable. The nurse should avoid confrontation and let the client know what she can do, rather than what she cannot. Although helpful to refocus or redirect the manic client to discuss only one topic at a time, distractibility is very high and it's best to avoid long discussions. Manic clients have a tendency to manipulate persons in their environment. Staff should monitor intake, including at mealtime and snacks, and be consistent in their approach to meeting nutritional needs. Manic clients may not sit and eat complete meals, but they can carry foods and liquids from regular meals with them. Staff can monitor and give high-caloric and high-energy snacks and liquids.
An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:
- A. A tension pneumothorax
- B. An asthma attack
- C. Pneumonia
- D. Pulmonary embolus
Correct Answer: B
Rationale: A tension pneumothorax is an accumulation of air in the pleural space. Important physical assessment findings to confirm this condition include cyanosis, jugular vein distention, absent breath sounds on the affected side, distant heart sounds, and lowered blood pressure. Asthma is a disorder in which there is an airflow obstruction in the bronchioles and smaller bronchi secondary to bronchospasm, swelling of mucous membranes, and increased mucus production. Physical assessment reveals some important findings: agitation, nasal flaring, tachypnea, and expiratory wheezing. Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung in the alveolar and interstitial tissue and results in consolidation. Specific assessment findings to confirm this condition include decreased chest expansion caused by pleuritic pain, dullness on percussion over consolidated areas, decreased breath sounds, and increased vocal fremitus. A pulmonary embolus is the passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into the pulmonary artery or its branches, with subsequent obstruction of blood supply to lung tissue. Specific assessment findings that confirm this condition include tachypnea, tachycardia, crackles (rales), transient friction rub, diaphoresis, edema, and cyanosis.
A client is being admitted to the labor and delivery unit. She has had previous admissions for 'false labor.' Which clinical manifestation would be most indicative of true labor?
- A. Increased bloody show
- B. Progressive dilatation and effacement of the cervix
- C. Uterine contractions
- D. Decreased discomfort with ambulation
Correct Answer: B
Rationale: Contractions of true labor produce progressive cervical effacement and dilatation.
Which method of transmission would most likely result in contamination with botulism?
- A. Close contact with a family member with botulism
- B. Eating foods from a perforated can
- C. Being bitten by a mosquito
- D. Wound contamination with C-botulism
- E. Contact with goat saliva
- F. Breathing dust from contaminated cat litter
Correct Answer: B, D
Rationale: Botulism is caused by Clostridium botulinum toxin, typically from contaminated food (e.g., perforated cans, B) or wound contamination (D). It is not transmitted person-to-person (A), via mosquitoes (C), goat saliva (E), or cat litter dust (F).
During burn therapy, morphine is primarily administered IV for pain management because this route:
- A. Delays absorption to provide continuous pain relief
- B. Facilitates absorption because absorption from muscles is not dependable
- C. Allows for discontinuance of the medication if respiratory depression develops
- D. Avoids causing additional pain from IM injections
Correct Answer: B
Rationale: IM injections are unreliable in burn patients due to fluid shifts into interstitial spaces, leading to poor absorption. IV administration ensures dependable absorption and effective pain relief.