Nokea
When caring for the child with autistic disorder, the nurse should:
- A. Take the child to the playroom to be with peers
- B. Assign a consistent caregiver
- C. Place the child in a ward with other children
- D. Assign several staff members to provide care
Correct Answer: B
Rationale: A consistent caregiver provides stability and reduces anxiety in a child with autism.
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A client with prostate cancer has been given the option of various treatments and asks the nurse for advice. Which of the following is the most appropriate response?
- A. Let's discuss the different options and how you feel about them.'
- B. I can't help you to make a treatment decision about your treatment.'
- C. You need to discuss this decision with your physician.'
- D. I would choose surgery if I were in your position.'
Correct Answer: A
Rationale: Discussing options and feelings (A) supports the client's decision-making without giving direct advice. Other responses (B, C, D) dismiss the client's request or overstep the nurse's role.
The nurse is caring for a client on airborne precautions. Which of the following would the nurse expect to see in the client's medical record?
- A. measles
- B. influenza
- C. Lyme disease
- D. herpes simplex
Correct Answer: A
Rationale: Measles requires airborne precautions due to its highly contagious nature via respiratory droplets, unlike the other conditions listed.
A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?
- A. A client with AIDS being treated with Foscarnet
- B. A client with a fractured femur in a long leg cast
- C. A client with laryngeal cancer with a laryngectomy
- D. A client with diabetic ulcers to the left foot
Correct Answer: A
Rationale: Foscarnet requires monitoring for toxicity, making this client a priority.
The physician has ordered a low-potassium diet for a client with acute glomerulonephritis. Which snack is suitable for the client with potassium restrictions?
- A. Raisins
- B. Oranges
- C. Apricots
- D. Bananas
Correct Answer: A
Rationale: Raisins are lower in potassium compared to oranges, apricots, and bananas, making them suitable for a low-potassium diet.
A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate?
- A. Reinsert the protruding organ and cover with 4x4s
- B. Cover the wound with a sterile 4x4 and ABD dressing
- C. Cover the wound with a sterile saline-soaked dressing
- D. Apply an abdominal binder and manual pressure to the wound
Correct Answer: C
Rationale: Covering the eviscerated wound with a sterile saline-soaked dressing keeps the protruding organs moist and prevents infection until surgical repair.