Nokea
The parents of a 4-year-old tell the nurse that the child won't go to sleep at night due to fear of tigers living under the bed. Which response by the nurse is most helpful?
- A. Have you recently visited the zoo? Maybe the tigers looked scary.
- B. If you agree with your child, the fears could continue through this developmental stage.
- C. Night fears are common at this age. Look under the bed with your child.
- D. This is very unusual. Maybe the child saw something scary on TV.
Correct Answer: C
Rationale: Night fears are normal in preschoolers (C). Checking under the bed with the child validates their fear while showing safety. Linking to a zoo visit (A) or media (D) assumes unconfirmed triggers. Agreeing with fears (B) may reinforce them.
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A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond?
- A. Ask about liver disease and give acetaminophen from the nurse's personal supply
- B. Check for allergies to drugs before giving acetaminophen from hospital stock
- C. Check the employee's blood pressure
- D. Refer employee to the employee's health care provider
Correct Answer: D
Rationale: Nurses cannot dispense medications without a prescription (A, B). Checking blood pressure (C) is irrelevant. Referring to a provider (D) ensures proper evaluation and treatment.
The nurse at the prenatal clinic is reinforcing education to a client who is HIV positive. Which information is appropriate for the nurse to include?
- A. Prescribed antiretroviral therapy should be continued during pregnancy
- B. Tetanus-diphtheria-acellular pertussis vaccine should be avoided until after birth
- C. The infant should be exclusively breastfed for 6 months to receive maternal antibodies
- D. The infant will not require treatment for HIV after birth
Correct Answer: A
Rationale: Continuing antiretroviral therapy (A) during pregnancy reduces HIV transmission to the infant. Tdap vaccine (B) is recommended in pregnancy. Breastfeeding (C) is contraindicated in HIV-positive mothers in high-resource settings. Infants (D) require prophylaxis post-birth.
The nurse in the mental health unit is talking with several clients during group therapy. A client becomes angry and throws a fire extinguisher at another client. Which of the following actions would be a priority for the nurse to take?
- A. Activate the rapid response team.
- B. Approach the client calmly and acknowledge the client's feelings.
- C. Escort other clients away from the area.
- D. Inform the client that the action was dangerous and unacceptable.
Correct Answer: C
Rationale: Ensuring safety by escorting others away (C) is the priority. Rapid response (A) may be premature, approaching the client (B) risks escalation, and informing of consequences (D) is secondary.
A client diagnosed with acute glomerulonephritis has pitting edema in the lower extremities, a blood pressure of 170/80 mm Hg, and proteinuria. When the practical nurse is assisting in the development of a care plan for this client, which measurement is the most accurate indicator of fluid loss or gain and should therefore be included in the plan?
- A. Blood pressure measurements
- B. Daily weight measurements
- C. Severity of pitting edema
- D. Strict intake and output measurements
Correct Answer: B
Rationale: Daily weights (B) are the most accurate for tracking fluid balance in glomerulonephritis. Blood pressure (A), edema (C), and intake/output (D) are less precise.
The physician has ordered dressings with sulfamylon cream for a client with full thickness burns of his hands and arms. Before dressing changes, the nurse should give priority to:
- A. Administering pain medication
- B. Checking the adequacy of urinary output
- C. Requesting a daily complete blood count
- D. Obtaining a blood glucose by finger stick
Correct Answer: A
Rationale: Sulfamylon dressing changes are painful, so administering pain medication is the priority. Urinary output , blood count , and glucose are important but secondary.