Nokea
Which action should the nurse take?
- A. Perform the procedure prior to meals.
- B. Perform chest physiotherapy immediately after feeding.
- C. Place the child in a supine position for the procedure.
- D. Limit fluid intake before the procedure.
Correct Answer: A
Rationale: The correct answer is A: Perform the procedure prior to meals. This is because performing the procedure before meals helps prevent potential complications such as aspiration during feeding. By emptying the stomach before meals, the risk of regurgitation and aspiration is reduced. Choices B, C, and D are incorrect because chest physiotherapy immediately after feeding can increase the risk of aspiration, placing the child in a supine position can also increase the risk of aspiration, and limiting fluid intake before the procedure may lead to dehydration and is not necessary for this specific procedure.
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Which of the following manifestations indicates that the client might be experiencing hypoglycemia?
- A. Confusion
- B. Increased thirst
- C. Frequent urination
- D. Flushed skin
Correct Answer: A
Rationale: The correct answer is A: Confusion. Hypoglycemia is a condition characterized by low blood sugar levels, leading to symptoms like confusion due to the brain not receiving enough glucose for energy. Increased thirst and frequent urination are more indicative of hyperglycemia (high blood sugar levels). Flushed skin is not a common manifestation of hypoglycemia.
The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.
- A. The client engages in quiet activities in their room
- B. The client slept 5 hr. the previous night
- C. The client consumes 8 oz of high-calorie fluids each hour
- D. The client takes 2 short naps during the day
- E. The client appears to listen to unseen others.
Correct Answer: A,B,C,D
Rationale: Improved behaviors include engaging in quiet activities, sleeping adequately, consuming fluids, and napping appropriately. Listening to unseen others indicates ongoing psychosis.
Which finding should the nurse identify as expected?
- A. Weak femoral pulses
- B. Bounding pulses in the lower extremities
- C. Cyanosis of the hands and feet
- D. Frequent episodes of bradycardia
Correct Answer: A
Rationale: The correct answer is A: Weak femoral pulses. In pediatric patients, weak femoral pulses are expected due to the normal physiological differences in vascular resistance between upper and lower extremities. This is known as the "femoral pulse lag." Bounding pulses in the lower extremities (choice B) would be abnormal and could indicate a vascular disorder. Cyanosis of the hands and feet (choice C) suggests poor perfusion and oxygenation, which is concerning. Frequent episodes of bradycardia (choice D) could indicate cardiac issues and are not expected in a healthy pediatric patient.
The nurse should identify which of the following situations as an example of interpersonal conflict?
- A. A nurse submits a complaint about another department's handoff reporting.
- B. A nurse feels stressed about an upcoming performance evaluation.
- C. A hospital policy change leads to disagreements among staff members.
- D. Two nurses disagree on how to handle a client's care plan.
Correct Answer: D
Rationale: The correct answer is D because it involves a conflict between two individuals, which is a key characteristic of interpersonal conflict. In this scenario, the conflict arises between two nurses regarding the client's care plan, indicating a disagreement in opinions or approaches. This type of conflict typically involves differences in perspectives, values, or goals between individuals. Choices A, B, and C do not involve direct conflicts between individuals but rather focus on complaints, stress, and policy disagreements that do not necessarily involve direct interpersonal conflicts. Therefore, option D is the most appropriate example of interpersonal conflict in this context.
A nurse is caring for a client whose child died from cancer. The client states 'it's hard to go on without him'. which of the following questions should the nurse ask the client first?
- A. What has helped you through difficult times in the past?
- B. Has anyone in your family committed suicide?
- C. Is there anyone you would like involved in your care?
- D. Are you thinking about ending your life?
Correct Answer: D
Rationale: The correct answer is D: Are you thinking about ending your life? This question is crucial as it directly addresses the client's statement about finding it hard to go on. It assesses the client's suicidal ideation and determines the level of risk for self-harm or suicide. It prioritizes the client's safety and well-being.
Choice A is incorrect because it does not directly address the immediate concern of potential suicide risk. Choice B is irrelevant and may lead to unnecessary distress for the client. Choice C is important but not as urgent as assessing for suicidal ideation.