Nokea
The school nurse observes a 7-year-old client with attention deficit hyperactivity disorder begin to throw books and attempt to hit the classmates. Which of the following actions would be a priority for the nurse to take?
- A. Ask the client to blow up a balloon.
- B. Administer a PRN dose of methylphenidate
- C. Place the client in a quiet room with supervision.
- D. Reinforce the consequences of disruptive behaviors.
Correct Answer: C
Rationale: Removing the client to a quiet room (C) ensures safety and de-escalates the situation. Balloon blowing (A) is inappropriate, PRN methylphenidate (B) is not typically ordered, and consequences (D) are secondary.
You may also like to solve these questions
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 in a same-day surgery unit assigns the unlicensed assistive personnel (UAP) to provide a hernia patient with a lunch tray. Which statement by the nurse is most appropriate?
- A. Tell the family they can bring in a pizza if the patient would prefer that.
- B. Make sure the patient gets at least 2 cartons of milk
- C. Stop the IV if the patient is able to eat solid food.
- D. Encourage the patient to eat slowly to prevent gas.
Correct Answer: D
Rationale: The professional nurse can delegate tasks with an expected outcome. The UAP is given adequate information about the task and how to promote the best outcome.
The nurse has attended a staff education program about obtaining blood specimens from newborns via heel stick. Which of the following statements by the nurse would require follow-up?
- A. Nonnutritive sucking may help alleviate pain during the puncture.
- B. I will obtain the blood specimen from the center of the newborn's heel.
- C. I will wipe away the first drop of blood prior to obtaining the specimen.
- D. The heel area should be warmed for 3 to 5 minutes prior to the puncture.
Correct Answer: B
Rationale: The center of the heel (B) should be avoided to prevent bone injury; lateral or medial aspects are used. Sucking (A), wiping the first drop (C), and warming (D) are correct.
An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help decrease the client's confusion by:
- A. Assigning a nursing assistant to sit with him until he falls asleep
- B. Allowing the client to room with another elderly client
- C. Administering a bedtime sedative
- D. Leaving a night light on during the evening and night shifts
Correct Answer: D
Rationale: A night light reduces confusion by improving visibility and orientation. Constant supervision is impractical, room-sharing may worsen confusion, and sedatives increase fall risk.
What is the most important aspect to include when developing a home care plan for a client with severe arthritis?
- A. Maintaining and preserving function
- B. Anticipating side effects of therapy
- C. Supporting coping with limitations
- D. Ensuring compliance with medications
Correct Answer: A
Rationale: Maintaining and preserving function. Preserving joint function is critical for quality of life in arthritis.