Nokea
The physician orders carbamazepine extended release (Tegretol-XR) for a client with cerebral palsy who also has a seizure disorder. The client has a gastrostomy feeding tube. What should the nurse do?
- A. Crush the medication and administer through the tube.
- B. Request an immediate-release formulation.
- C. Withhold the medication and notify the physician.
- D. Administer the medication orally.
Correct Answer: C
Rationale: Extended-release formulations like Tegretol-XR should not be crushed; the nurse should notify the physician to adjust the order.
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Which of the following client actions should the nurse judge to be a healthy coping behavior for a male adolescent after an appendectomy?
- A. Insisting on wearing a T-shirt and gym shorts rather than pajamas.
- B. Avoiding interactions with other adolescents on the nursing unit.
- C. Refusing to fill out the menu, and allowing the nurse to do so.
- D. Not taking telephone calls from friends so he can rest.
Correct Answer: A
Rationale: Choosing preferred clothing reflects autonomy and positive coping.
When developing the plan of care for a neonate who was diagnosed with an anorectal malformation and who subsequently underwent surgery, which of the following would be most helpful in facilitating parent-infant bonding?
- A. Explaining to the parents that they can visit at any time.
- B. Encouraging the parents to hold their infant.
- C. Asking the parents to help monitor the infant's intake and output.
- D. Helping the parents plan for their infant's discharge.
Correct Answer: B
Rationale: Physical contact through holding fosters bonding and emotional connection.
The nurse is teaching the parents of an 8-month-old about what the child should be eating. The nurse should include which of the following points in the teaching plan?
- A. Items from all four food groups should be introduced to the infant by the time the child is 10 months old.
- B. Solid foods should not be introduced until the infant is 10 months old.
- C. Iron deficiency rarely develops before 12 months of age, so iron-fortified cereals should not be introduced until the infant is 12 months old.
- D. The infant's diet can be changed from formula to whole milk when the infant is 12 months old.
Correct Answer: D
Rationale: Whole milk can be introduced at 12 months, as infants need the fat content for brain development.
A nurse is assessing a child who is mildly mentally retarded. The best indication of how a mentally retarded child is progressing can be obtained by observing him:
- A. At school with his teacher.
- B. At home with his family.
- C. In the clinic with his mother.
- D. Playing soccer with his friends.
Correct Answer: B
Rationale: Observing the child at home provides insight into daily functioning and adaptive behavior in a familiar environment, reflecting progress accurately.
When planning a visit to the parents of an infant who died of sudden infant death syndrome (SIDS) at home, the nurse should visit the parents at which of the following times?
- A. A few days after the funeral.
- B. Two weeks after the funeral.
- C. As soon as the parents are ready to talk.
- D. As soon after the infant's death as possible.
Correct Answer: C
Rationale: Visiting as soon as the parents are ready to talk respects their grieving process and ensures they are emotionally prepared to receive support.