Nokea
When developing the plan of care for a 14-year-old boy with a nursing diagnosis of Deficient diversional activity related to immobility, which of the following activities is most appropriate?
- A. Playing a card game with a boy the same age.
- B. Putting together a puzzle with his mother.
- C. Playing video games with a 9-year-old.
- D. Watching a movie with his younger brother.
Correct Answer: A
Rationale: A peer-based activity like a card game promotes social interaction and engagement, suitable for a 14-year-old's developmental needs.
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Based on the fact that you family unit client is experiencing a situational crisis that has led to dysfunctional communication within the family unit, you have recommended that the entire nuclear family and members of the extended family who live in the family's home begin family therapy. The grandparents tell you that it is their grandson, rather than their son, who is addicted to prescription painkillers, is the cause of the problem; therefore, they do not have to participate in this group therapy. How should you respond to these grandparents?
- A. You should try to come to a few sessions at least because they may be very informative to you'.
- B. You are probably correct. This really is not your problem'.
- C. Despite the fact that it is your grandson's drug addiction, situations such as this affect all members of the family including grandparents who live in the home.'
- D. You should attend because the doctor has ordered family therapy for you as extended family members'.
Correct Answer: C
Rationale: Addiction affects the entire family system, including extended family members living in the home. Their participation in therapy can help address dysfunctional communication and support the family unit as a whole.
You are preparing to administer a PRN medication for pain. After your assessment of the client for pain you open the narcotics cabinet with the special key. Your calculations indicate that the client will be getting 0.8 mLs of the medication and the unit dose vial is 1 mL. You discard the excess of 0.2 mLs into the sink drain and enter the client's room. After you identify the client using two unique identifiers, the client refuses the medication. You then discard the 0.8 mLs into the sink and document the client's refusal on the narcotics count record. What have you failed to do during this process?
- A. You have failed to have another nurse witness the 0.8 mLs and the 0.2 mLs of waste.
- B. You have failed to have another nurse witness the 0.8 mLs of waste.
- C. You have failed to have another nurse witness the 0.2 mLs of waste.
- D. You have failed ask another nurse to verify the calculation of the dosage.
Correct Answer: A
Rationale: Narcotic wastage (both 0.2 mL and 0.8 mL) requires a witness to ensure accountability and prevent diversion, per standard protocol.
Which is most closely aligned with ethics?
- A. Morals
- B. Laws
- C. Statutes
- D. Client rights
Correct Answer: A
Rationale: Ethics is most closely aligned with morals , as both involve principles of right and wrong that guide behavior, whereas laws and statutes are legal frameworks, and client rights are specific entitlements.
The nurse is performing Leopold’s maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown below. Which of the following maneuvers is the nurse performing?
- A. First maneuver.
- B. Second maneuver.
- C. Third maneuver.
- D. Fourth maneuver.
Correct Answer: C
Rationale: The third maneuver is used to identify the presenting part. This maneuver is used to identify the part of the fetus that lies over the inlet to the pelvis. While facing the client, the nurse places the tips of the fi rst three fi ngers on the side of the woman’s abdomen above the symphysis pubis and palpates deeply around the presenting part to identify its contour and size. The first maneuver involves using the tips of the fi ngers of both hands to palpate the uterine fundus. The second maneuver identifi es the back of the fetus, and the fourth maneuver identifies the cephalic prominence
The nurse is caring for a client with a history of hyperthyroidism who is prescribed methimazole (Tapazole). The nurse should monitor the client for which of the following adverse effects?
- A. Agranulocytosis.
- B. Hypertension.
- C. Hyperglycemia.
- D. Weight loss.
Correct Answer: A
Rationale: Methimazole can cause agranulocytosis, a serious reduction in white blood cells, requiring monitoring.