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What is a common significant side effect of opioid administration?
- A. Euphoria
- B. Diuresis
- C. Constipation
- D. Allergic reactions
Correct Answer: C
Rationale: Constipation is one of the most common side effects of opioid administration due to the slowing down of gastrointestinal motility. Opioids affect the bowel movements, leading to constipation. Euphoria, while a possible effect, is less common than constipation. Diuresis is not a typical side effect of opioids; instead, urinary retention may occur. Allergic reactions are rare side effects of opioids, with symptoms such as rash, itching, or anaphylaxis.
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In planning care for children, the nurse considers children's anxiety about hospitalization. Which measure should be included in the child's plan of care to help reduce anxiety?
- A. Therapeutic play
- B. Time-out
- C. Counseling
- D. Movies
Correct Answer: A
Rationale: Therapeutic play should be included in the child's plan of care to help reduce anxiety during hospitalization. It is an effective strategy that allows children to express their feelings, understand procedures, and reduce anxiety levels. Time-out (choice B) is not suitable for addressing anxiety related to hospitalization. Counseling (choice C) may be beneficial but is not as specifically tailored to reduce anxiety in the hospital setting as therapeutic play. Movies (choice D) may provide a temporary distraction but do not actively involve the child in addressing their emotions and fears associated with hospitalization.
The nurse is caring for a 1-month-old infant diagnosed with Hirschsprung's disease. Which treatment measure should be included in the plan of care?
- A. Barium Enema
- B. Surgical removal of the affected section of bowel
- C. High-fiber diet
- D. Permanent colostomy
Correct Answer: B
Rationale: The correct answer is B: Surgical removal of the affected section of bowel. Hirschsprung's disease is a congenital condition where a portion of the large intestine lacks nerve cells, leading to difficulties in passing stool. The definitive treatment for this condition is the surgical removal of the affected section of the bowel. Barium enema (Choice A) may be used for diagnosis but is not a treatment. A high-fiber diet (Choice C) is not effective in managing Hirschsprung's disease. A permanent colostomy (Choice D) is not the initial treatment for this condition in infants.
A child with nephrotic syndrome is severely edematous. The primary healthcare provider has placed the child on bed rest. Which nursing intervention should be included in the plan of care?
- A. Monitor blood pressure every 30 minutes.
- B. Reposition the child every two hours.
- C. Limit visitors.
- D. Encourage fluids.
Correct Answer: B
Rationale: Repositioning the child every two hours is essential to prevent pressure ulcers and promote circulation, especially when the child is on bed rest and experiencing severe edema. Monitoring blood pressure is important but does not need to be done every 30 minutes unless indicated. Limiting visitors and encouraging fluids are not directly related to managing edema and preventing complications from immobility. Therefore, choice B is the most appropriate nursing intervention in this scenario.
The nurse is teaching a nursing student about standard precautions. Which statement made by the student indicates a need for further teaching?
- A. I will use precautions when I give an infant oral care
- B. I will use precautions when I change an infant's diaper
- C. I will use precautions when I come in contact with blood and body fluids
- D. I will use precautions when administering oral medications to a school-age child
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which nursing intervention should be included in the postoperative care of a child following a tonsillectomy?
- A. Encourage the child to blow the nose gently
- B. Notify the physician if mucus is observed in the emesis
- C. Position the child supine in the immediate postoperative period
- D. Avoid giving citrus juice
Correct Answer: D
Rationale: The correct answer is D: 'Avoid giving citrus juice.' Citrus juice can irritate the throat after a tonsillectomy, so it should be avoided. Choice A is incorrect because blowing the nose gently is not a recommended intervention following a tonsillectomy. Choice B is incorrect as mucus in emesis is not uncommon postoperatively and does not necessarily require physician notification. Choice C is incorrect as positioning the child supine immediately postoperatively can increase the risk of airway obstruction and should be avoided.