Nokea
The parents of a 2-year-old client ask how they can help their child cope with hospitalization. Which of the following suggestions should the nurse give the parents? Select all that apply.
- A. Follow as many home routines as possible
- B. Organize a visit from a playgroup friend
- C. Sleep in the child's hospital room at night
- D. Take child on regular visits to the playroom
- E. Tell the child they did not cause the illness
Correct Answer: A,C,E
Rationale: Maintaining home routines, parental presence, and reassuring the child about the cause of illness help reduce anxiety and promote coping during hospitalization.
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A 4-year old is scheduled for a routine tonsillectomy. Which of the following lab findings should be reported to the doctor?
- A. A hemoglobin of $12 \mathrm{gm}$
- B. A platelet count of $200,000 \mathrm{cu} \mathrm{mm}$
- C. A white cell count of $16,000 \mathrm{cu} \mathrm{mm}$
- D. A urine specific gravity of 1.010
Correct Answer: C
Rationale: A white cell count of 16,000 is elevated, suggesting infection, which must be reported before surgery. Hemoglobin , platelets , and urine specific gravity are normal.
An adult woman has been diagnosed with varicose veins. Which aspect of her history is most likely related to her diagnosis?
- A. She has had five term pregnancies.
- B. She runs several marathons a year.
- C. She is 5 feet, 6 inches tall and weighs 120 pounds.
- D. She works entering data into a computer.
Correct Answer: A
Rationale: Multiple pregnancies increase intra-abdominal pressure and venous stasis, contributing to varicose veins. Running, normal weight, and sedentary work are less directly related.
The nurse is reinforcing teaching to a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include? Select all that apply.
- A. Avoid excess caffeine
- B. Immerse hands in cold water
- C. Practice yoga or tai chi
- D. Refrain from using tobacco products
- E. Wear gloves when handling cold objects
Correct Answer: A,C,D,E
Rationale: Caffeine, tobacco, and cold exposure can trigger Raynaud episodes. Yoga/tai chi and gloves help prevent attacks. Cold water immersion exacerbates symptoms.
The mother of a 1-week-old infant says to the nurse, 'When will that ugly black cord thing come off?' How should the nurse reply?
- A. Are you wiping it with alcohol each time you change the baby's diaper?'
- B. It usually comes off in 10 days to three weeks.'
- C. It sounds as if it bothers you. Would you like to talk about it?'
- D. It should be off by now. I'll have the doctor check to be sure there is no problem.'
Correct Answer: B
Rationale: The umbilical cord typically detaches in 10 days to 3 weeks, providing accurate information. Other responses are irrelevant or incorrect.
Which of the following drug administrations should be reported as a practice error? Select all that apply.
- A. Cephalexin administered; client has history of anaphylaxis from penicillin
- B. Hydromorphone 2 mg administered; client reports pruritus
- C. Immunization for 3-month-old administered in ventrogluteal site
- D. Oral niacin (nicotinic acid) administered; client has facial flushing
- E. Warfarin administered; client at 12 weeks gestation
Correct Answer: A,E
Rationale: Cephalexin in a penicillin-allergic client risks anaphylaxis, and warfarin in pregnancy can cause fetal harm. Pruritus and flushing are expected side effects, and the ventrogluteal site is appropriate.