Nokea
The pediatric nurse cares for a 16-year-old client who is scheduled for an appendectomy in the morning. Which of the following interventions are appropriate to support the client's psychosocial needs?
- A. Create a strict daily schedule for the client while hospitalized
- B. Encourage the client to have peers visit while hospitalized
- C. Ensure parental presence during any client procedure
- D. Include the client as an active participant when planning care
- E. Support the client in discussing concerns about body image changes
Correct Answer: B,D,E
Rationale: Peer visits (B), active participation (D), and addressing body image (E) support a teen's psychosocial needs. Strict schedules (A) reduce autonomy, and parental presence (C) may not align with the teen's preferences.
You may also like to solve these questions
The practical nurse (PN) is assisting with care for a 1-day-old client who is irritable, feeding poorly, and only sleeping for very short intervals. The newborn's mother has been taking hydrocodone on a regular basis for several years. When collaborating with the registered nurse to develop the plan of care, which intervention should the PN include?
- A. Avoid giving the newborn a pacifier
- B. Position the newborn supine after feeding
- C. Stimulate the newborn with light regularly
- D. Swaddle and gently rock the newborn
Correct Answer: D
Rationale: Swaddling and rocking (D) soothe a newborn with neonatal abstinence syndrome due to maternal hydrocodone use. Pacifiers (A) are helpful, supine positioning (B) is for safety but not soothing, and stimulation (C) may worsen irritability.
A client complains of some discomfort after a below the knee amputation. Which action by the nurse is most appropriate initially?
- A. Conduct guided imagery or distraction
- B. Ensure that the stump is elevated the first day post-op
- C. Wrap the stump snugly in an elastic bandage
- D. Administer opioid narcotics as ordered
Correct Answer: B
Rationale: Ensure that the stump is elevated the first day post-op. This priority intervention prevents pressure caused by pooling of blood, thus minimizing the pain. Without this measure, a firm elastic bandage, opioid narcotics, or guided imagery will have little effect. Opioid narcotics are given for severe pain.
The nurse is reviewing a nutritional plan for a 6-month-old who has recently been started on solid foods. Which of the following recommendations has the highest priority in the plan?
- A. Canned baby food is more expensive than food prepared at home
- B. Finger foods can be introduced before the child has teeth
- C. New foods should be introduced at least 5-7 days apart
- D. Rice cereal can be mixed with cow's milk to increase nutritional intake
Correct Answer: C
Rationale: Introducing new foods 5-7 days apart (C) prevents allergic reactions by identifying triggers, making it the priority. Cost (A), finger foods (B), and cow's milk (D, not recommended before 12 months) are secondary.
The nurse has been made aware of laboratory test results for a client who is receiving continuous cardiac monitoring. The client is asymptomatic, and the cardiac monitor shows normal sinus rhythm. Which of the following is most likely an erroneous test result?
- A. BUN of 60 mg/dL (21.4 mmol/L)
- B. serum sodium level of 155 mEq/L (155 mmol/L)
- C. serum potassium level of 7.0 mEq/L (7.0 mmol/L)
- D. serum creatinine level of 4.0 mg/dL (353.6 μmol/L)
Correct Answer: C
Rationale: A potassium level of 7.0 mEq/L (C) is life-threatening and would likely cause arrhythmias, inconsistent with normal sinus rhythm and asymptomatic status, suggesting an error. Elevated BUN (A), sodium (B), and creatinine (D) are concerning but plausible in renal or dehydration issues without immediate cardiac effects.
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.