Nokea
Which behaviors by the nurse indicate therapeutic nurse-family boundaries? (Select all that apply.)
- A. Nurse visits family on days off.
- B. House rules are negotiated.
- C. Nurse buys child expensive gifts.
- D. Communication is open and two-way.
Correct Answer: B
Rationale: House rules are negotiated: In maintaining therapeutic nurse-family boundaries, it is important for the nurse to establish clear and appropriate boundaries by involving the family in negotiating house rules. This helps to define roles and responsibilities, promoting mutual respect and understanding between the nurse and the family. By negotiating house rules, the nurse can create a structured environment that supports the well-being of the family.
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A 13-year-old boy is hospitalized for a femur fracture after being hit by a car while racing bikes. The parents are concerned about his judgment. The nurse should tell the parents that this behavior is:
- A. Typical of young teens.
- B. Related to hormonal surges during adolescence.
- C. An isolated incident that will not likely happen again.
- D. Related to underdeveloped judgment and impulse control in adolescence.
Correct Answer: D
Rationale: The adolescent brain is still developing, which can lead to poor judgment and impulsive behavior.
Nurse Dorothy is caring for a child with Cushing's syndrome; which of the following should she include in the plan of care?
- A. Increase fluids to prevent dehydration
- B. Encourage a diet high in carbohydrates
- C. Monitor weight each day and report for weight loss
- D. Encourage a diet high in potassium
Correct Answer: C
Rationale: When caring for a child with Cushing's syndrome, it is important to monitor weight each day and report any weight loss. Cushing's syndrome is characterized by a metabolic disorder that can lead to weight gain, particularly in the abdominal area. However, sudden weight loss in a child with Cushing's syndrome can be a sign of worsening condition or inadequate treatment. Therefore, monitoring weight regularly is crucial in managing the child's condition and adjusting the treatment plan accordingly.
Inhalation of carbogen for short period is recommended:
- A. To stimulate respiration
- B. To dilate blood vessels
- C. To dislodge the blood clot
- D. All of the above
Correct Answer: D
Rationale: Inhalation of carbogen, which is a mixture of carbon dioxide and oxygen, for a short period can have several beneficial effects.
A 2-year-old is noted to be drinking from a container filled with kerosene. He immediately coughs, becomes tachypneic, and is brought to the hospital. The best approach to his treatment is to
- A. induce emesis
- B. perform nasogastric tube lavage
- C. instill mineral oil
- D. administer steroids
Correct Answer: E
Rationale: Inducing emesis or performing gastric lavage can increase the risk of aspiration. The best approach is supportive care, including oxygen and monitoring.
A client has the following blood lab values: platelets 50,000/ul, RBC's 3.5 (X 106), hemoglobin 10 g/dl, hematocrit 30 percent, WBCs 10,000/ul. Which nursing instruction should be included in the teaching plan?
- A. Bleeding precautions
- B. Isolation to prevent infection
- C. Seizure precautions
- D. Control of pain with analgesics
Correct Answer: A
Rationale: The client's platelet count of 50,000/ul is significantly low (normal range is around 150,000-450,000/ul). A low platelet count places the client at risk for bleeding tendencies. Therefore, the most appropriate nursing instruction to include in the teaching plan is bleeding precautions. This would involve educating the client on measures to prevent bleeding such as avoiding activities that may cause injury, using a soft toothbrush, avoiding tight clothing, and being cautious while shaving.