Nokea
The practical nurse is performing a physical examination with the registered nurse on a 2-year-old with cold symptoms and a fever at home of 101.7 F (38.7 C). Which interventions will enhance the child's cooperation during the examination? Select all that apply.
- A. Allow the child to play with the stethoscope
- B. Begin with the child in the parent's lap
- C. Interact with the parent in a friendly manner
- D. Play with the child using a finger puppet
- E. Start by taking the child's vital signs
Correct Answer: A,B,C,D
Rationale: Playing with the stethoscope (A), starting in the parent's lap (B), friendly interaction (C), and using a puppet (D) reduce anxiety and enhance cooperation. Vital signs (E) may distress the child if done first.
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The nurse is caring for a depressed client with a new prescription for a selective serotonin reuptake inhibitor (SSRI) antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication?
- A. History of obesity
- B. Prescribed use of a monoamine oxidase (MAO) inhibitor
- C. Diagnosis of vascular disease
- D. Takes antacids frequently
Correct Answer: B
Rationale: SSRIs should not be taken concurrently with MAO inhibitors because serious, life-threatening reactions may occur with this combination of drugs.
A charge nurse working in a long term care facility is making out assignments. Which assignment made by a registered nurse to an unlicensed assistive personnel (UAP) requires intervention by the supervisor?
- A. Provide decubitus ulcer care and apply a dry dressing
- B. Bathe and feed a client on bed rest
- C. Oral suctioning of an unresponsive elderly client
- D. Teaching a family intermittent (bolus) feedings via G-tube before discharge
Correct Answer: D
Rationale: Teaching a family intermittent (bolus) feedings via G-tube before discharge. Initial teaching cannot be delegated to a UAP or a PN and must be done by RNs.
The nurse is providing care to a 9-year-old client who is awaiting surgery. Which intervention is developmentally appropriate for this client's plan of care?
- A. Discuss the procedure with the client using simple diagrams with correct anatomical terminology
- B. Explore the client's perception of how the surgery will positively affect their future
- C. Focus primarily on the client's feelings and concerns regarding surgical scar appearance
- D. Provide initial education about the procedure to the client immediately before it is performed
Correct Answer: A
Rationale: Using simple diagrams with correct terminology (A) is age-appropriate for a 9-year-old, aiding understanding. Future benefits (B) are abstract, scar concerns (C) are secondary, and last-minute education (D) increases anxiety.
The nurse is assessing a 7-year-old client who was recently admitted with nausea, vomiting, severe right lower quadrant pain, and an elevated WBC count. Which of the following statements by the client would be a priority to follow up?
- A. I feel so tired.
- B. I am hungry and I want to eat.
- C. My stomach does not hurt anymore.
- D. I do not like hospitals and I want to go home.
Correct Answer: C
Rationale: Resolution of pain (C) in suspected appendicitis may indicate perforation, a surgical emergency, requiring urgent follow-up. Fatigue (A), hunger (B), and dislike of hospitals (D) are less critical.
A client with acquired immunodeficiency syndrome is admitted for treatment of wasting syndrome. Which of the following dietary modifications can be used to compensate for the limited absorptive capability of the intestinal tract?
- A. Thoroughly cooking all foods
- B. Offering yogurt and buttermilk between meals
- C. Forcing fluids
- D. Providing small, frequent meals
Correct Answer: D
Rationale: Small, frequent meals are easier to digest and absorb, compensating for the limited absorptive capacity in wasting syndrome. Cooking foods thoroughly reduces infection risk but doesn't aid absorption. Yogurt and buttermilk may not be tolerated, and forcing fluids addresses hydration, not absorption.