Nokea
The school nurse is teaching a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates that further teaching is necessary?
- A. I should have a bottle of Ipecac for each of my children.'
- B. I should induce vomiting if my child swallows lighter fluid.'
- C. Giving my child water or milk may help dilute the poison.'
- D. Proper storage is the key to poison prevention in the home.'
Correct Answer: B
Rationale: Inducing vomiting after ingesting hydrocarbons like lighter fluid is contraindicated due to the risk of aspiration, which can cause severe lung damage. Choice A is correct (Ipecac dosing is appropriate), choice C is accurate (dilution can help), and choice D is true (locked storage prevents poisoning). Further teaching is needed for choice B.
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The nurse is caring for a client with a history of bipolar disorder who is prescribed lithium. Which of the following laboratory values should the nurse monitor?
- A. Serum sodium.
- B. Serum glucose.
- C. Serum calcium.
- D. Serum hemoglobin.
Correct Answer: A
Rationale: Lithium can cause hyponatremia, and monitoring serum sodium ensures safe levels (therapeutic lithium range: 0.6–1.2 mEq/L). Glucose (B), calcium (C), and hemoglobin (D) are not directly affected by lithium therapy.
The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be
- A. Reduce fear and protect self-esteem
- B. Minimize anxiety and delay apprehension
- C. Avoid conflict and leave unpleasant situations
- D. Increase independence and communicate more often
Correct Answer: A
Rationale: Reduce fear and protect self-esteem. Ego defense mechanisms are unconscious proactive barriers that are used to manage instinct and affect in the presence of stressful situations. Healthy reactions are those in which the client admits that they are feeling various emotions.
A new mother has some questions about PKU.
Which of the following statements made by the nurse is correct regarding PKU?
- A. An amniocentesis is required prior to delivery.
- B. PKU test is performed soon after birth.
- C. PKU is preventable if the mother eats adequate amount of protein during pregnancy.
- D. The effects of PKU are irreversible
Correct Answer: B
Rationale: The PKU test is performed shortly after birth to detect phenylalanine levels.
The nurse is caring for a preschooler who needs stitches resulting from an injury received during play in the yard. What would be the most appropriate way to prepare the child for the treatment he will receive?
- A. Tell the child the nurse and the doctor will 'make things all better.'
- B. Use dolls and explain through play and simulation what will be done.
- C. Explain to the child slowly and precisely the steps that will be taken in his treatment.
- D. Tell the child that he will have minimal scarring and that any marks will diminish over time.
Correct Answer: B
Rationale: Play-based explanation with dolls engages a preschooler's developmental level, effectively preparing them for stitches.
A client's vision is to be evaluated using the Ishihara exam. The nurse recognizes that the client will be checked for:
- A. Macular degeneration
- B. Astigmatism
- C. Color blindness
- D. Glaucoma
Correct Answer: C
Rationale: The Ishihara exam tests for color blindness by assessing color perception. It does not evaluate macular degeneration, astigmatism, or glaucoma.