Nokea
The school nurse is conducting an educational session for middle school teachers that is designed to heighten awareness of school bullying. The nurse recognizes that further instruction is needed when one of the teachers makes which comment?
- A. Bullying is a normal part of childhood growth and development.
- B. Children with physical disabilities are more vulnerable to bullying.
- C. Most children who are victims of a school bully do not tell an adult about it.
- D. The most common form of bullying is verbal aggression, such as insults and intimidation.
Correct Answer: A
Rationale: Bullying is not a normal part of development (A) and requires intervention. Vulnerability of disabled children (B), underreporting (C), and verbal aggression (D) are accurate.
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A parent has numerous questions regarding normal growth and development of a 10 month-old infant. Which of the following parameters is of most concern to the nurse?
- A. 50% increase in birth weight
- B. Head circumference greater than chest
- C. Crying when the parents leave
- D. Able to stand up briefly in play pen
Correct Answer: A
Rationale: 50% increase in birth weight. Birth weight should double by 6 months, indicating potential growth issues that require further evaluation.
A client has developed diabetes insipidus after removal of a pituitary tumor. Which finding would the nurse expect?
- A. Polyuria
- B. Hypertension
- C. Polyphagia
- D. Hyperkalemia
Correct Answer: A
Rationale: Clients with diabetes insipidus have excessive urinary output due to a lack of antidiuretic hormone. Answers B, C, and D are not exhibited with diabetes insipidus, so they are incorrect.
An adult is scheduled for a paracentesis. What should the nurse plan to do immediately before the procedure is started?
- A. Give the client a full glass of water
- B. Have the client empty his/her bladder
- C. Ask the client to empty his/her bowels
- D. Administer diazepam (Valium) as ordered
Correct Answer: B
Rationale: Emptying the bladder before paracentesis prevents accidental puncture of the bladder during needle insertion into the abdominal cavity. Water intake, bowel emptying, or sedation are not immediate pre-procedure priorities.
The nurse is caring for a client who had a forceps-assisted vaginal birth and is reporting severe vaginal pain and fullness. The nurse notes the fundus is firm and midline with a scant amount of lochia rubra. The client is most likely experiencing
- A. uterine atony
- B. vaginal hematoma
- C. cervical lacerations
- D. inversion of the uterus
Correct Answer: B
Rationale: Severe vaginal pain and fullness with a firm fundus and scant lochia suggest a vaginal hematoma (B). Uterine atony (A) causes heavy bleeding, cervical lacerations (C) cause bleeding, and uterine inversion (D) involves a displaced fundus.
The nurse is reinforcing teaching about infant safety to a class of expectant parents. Which statement by a participant indicates a need for further instruction?
- A. I will allow my baby to sleep with a pacifier.
- B. I will dress my baby in a sleeping sack to prevent my baby from getting cold.
- C. I will make sure there is a firm mattress in the crib.
- D. I will only place one teddy bear in the crib to comfort my baby
Correct Answer: D
Rationale: Placing a teddy bear in the crib (D) increases suffocation risk, requiring further teaching. Pacifiers (A), sleep sacks (B), and firm mattresses (C) are safe.