Nokea
History and Physical
Nurses Notes
The client is a 4-year-old male with a history of prematurity, short gut syndrome, and liver and bowel transplant. He has been hospitalized for the past 8 months, 6 of those were spent in the pediatric intensive care unit. He is currently in the pediatric unit for observation as his post transplant medications are stabilized for discharge.
Which action(s) is/are appropriate for the nurse caring for this child? Select all that apply.
- A. Avoid mentioning anything about the mother to the child.
- B. Develop a trusting relationship with the child.
- C. Notify the mother that social services will be notified if she does not visit regularly.
- D. Have the child sign a treatment contract stating he will participate in therapy.
- E. Ask the mother to bring a familiar object from home.
- F. Facilitate phone conversations between the child and his mother.
Correct Answer: B,E,F
Rationale: Building trust, providing familiar objects, and facilitating mother-child communication support the child's emotional well-being during hospitalization.
You may also like to solve these questions
The nurse is providing discharge instructions to the caregiver of an infant with recurrent otitis media. Which statement made by the caregiver should the nurse recognize as needing additional education about minimizing subsequent infections?
- A. Avoid any smoking inside the house.
- B. Give infant the full course of antibiotics.
- C. Schedule visit for pneumococcal vaccine.
- D. Instill benzocaine otic drops regularly.
Correct Answer: D
Rationale: Benzocaine otic drops provide pain relief but do not prevent infections. Regular use may mask symptoms, delaying treatment. Avoiding smoke, completing antibiotics, and vaccinating reduce infection risk.
History and Physical
Nurses' Notes
Flow Sheet
Laboratory Results
38-year-old primiparous client is seen in the outpatient obstetric office 2 weeks postpartum after a spontaneous vaginal birth of a full-term infant after rupture of membranes for 16 hours. The client was discharged on day 2, exclusively breastfeeding.
Which education by the nurse will help resolve the issue for the client? Select all that apply.
- A. Wear an underwire bra around the clock.
- B. Apply warm compresses to affected area before feeding.
- C. Pump breasts if feeding will be missed, due to absence from the infant.
- D. Pump breastmilk and feed it to infant instead of nursing.
- E. Finish antibiotics even if symptoms improve.
- F. Maintain activity due to the risk of blood clots with extra rest.
- G. Wash hands before handling the breast.
Correct Answer: B,C,E,G
Rationale: Warm compresses, pumping to prevent milk stasis, completing antibiotics, hand hygiene, starting on the unaffected side, and varying positions promote milk flow, reduce infection risk, and ensure effective breastfeeding. Underwire bras and avoiding rest are not recommended.
History and Physical
Nurses' Notes
Flow Sheet
Vital signs
The client is a 9-month-old male who was born by cesarean section at 32 weeks gestation. He has been hospitalized once with respiratory syncytial virus at 2 months of age. He is up to date on vaccines.
Exhibits
Review H and P, nurse's note, and flow sheet.
Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Remove some of the baby's clothing
- B. Clean the area with warm water
- C. Alert child protective services
- D. Swab the area and send for a culture
- E. Hold the vaccines
- F. Temperature
- G. Parent's understanding of education
Correct Answer: A,B
Rationale: Miliaria, caused by overdressing, is addressed by removing clothing and cleaning with warm water. Monitoring temperature and parental education prevents recurrence.
Which drink choice on a hot day indicates to the nurse that an adolescent with sickle cell anemia understands dietary considerations related to the disease?
- A. Diet cola.
- B. Ice tea.
- C. Lemonade.
- D. Milkshake.
Correct Answer: C
Rationale: Lemonade, a hydrating, caffeine-free drink, prevents dehydration, reducing sickling risk in sickle cell anemia.
A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks the nurse what is the purpose of the ointment. Which response by the nurse will best explain the purpose for administering the ointment?
- A. The ointment will prevent a herpes infection.'
- B. The ointment will clear the infant's vision.'
- C. The ointment will dilate the pupil so the red reflex can be visualized.'
- D. The ointment will prevent eye infections.'
Correct Answer: D
Rationale: Erythromycin ointment prevents ophthalmia neonatorum from gonorrhea or chlamydia, reducing blindness risk.