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Which interventions are appropriate to include in the plan of care for a child after a tonsillectomy?
- A. Offer clear, cool liquids when awake.
- B. Administer pain medication as prescribed
- C. Monitor for bleeding from the surgical site.
- D. Suction every 15 minutes and PRN as necessary.
- E. Initially eliminate milk or milk products from the diet.
Correct Answer: A,B,C,E
Rationale: After tonsillectomy, clear, cool liquids are encouraged. Options 2 and 3 are important interventions after any type of surgery. Suction equipment should be available, but suctioning is not performed unless there is an airway obstruction. Milk and milk products are avoided initially because they coat the throat; this causes the child to clear the throat, thereby increasing the risk of bleeding.
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The nurse is admitting a client who recently underwent a bilateral adrenalectomy. Which intervention is essential for the nurse to include in the client's plan of care?
- A. Prevent social isolation.
- B. Consider occupational therapy.
- C. Discuss changes in body image.
- D. Avoid stress-producing situations.
Correct Answer: D
Rationale: Adrenalectomy can lead to adrenal insufficiency. Adrenal hormones are essential to maintaining homeostasis in response to stressors. None of the remaining options are essential interventions specific to this client's problem.
A client who was a victim of a gunshot incident states, 'I feel like I am losing my mind. I keep hearing the gunshots and seeing my friend lying on the ground.' Which strategy should the nurse include when initially formulating a therapeutic relationship?
- A. Teaching the client a variety of relaxation techniques
- B. Asking the psychiatrist to prescribe appropriate medication
- C. Encouraging the client to talk about the incident and feelings related to it
- D. Encouraging the client to think about just how lucky he or she is to still be alive
Correct Answer: C
Rationale: When developing a therapeutic relationship, it is important to acknowledge and validate the client's feelings. Although teaching the client relaxation techniques may be helpful at some point, it is not related to the subject of the question. Options 2 and 4 are nontherapeutic techniques, and they do not promote a therapeutic relationship.
The nurse plans care for a client with alcohol abuse disorder based on which support system?
- A. Fresh Start, is an option for families of addicts.
- B. Families Anonymous, an option for those addicted to nicotine.
- C. Al-Anon, an option for parents of children who abuse substances.
- D. Alcoholics Anonymous, a major self-help organization for the treatment of alcohol abuse.
Correct Answer: D
Rationale: Alcoholics Anonymous is a major self-help organization for the treatment of alcoholism. Option 1 is a group for families of alcoholics. Option 2 is for nicotine addicts. Option 3 is for the parents of children who abuse substances.
The nurse is caring for a postpartum client with thromboembolytic disease. Which intervention is most important to include when planning care to prevent the complication of pulmonary embolism?
- A. Enforce bed rest.
- B. Monitor the vital signs frequently.
- C. Assess the breath sounds frequently.
- D. Administer prescribed anticoagulant therapy.
Correct Answer: D
Rationale: The purposes of anticoagulant therapy for the treatment of thromboembolytic disease are to prevent the formation of a clot and to prevent a clot from moving to another area, thus preventing pulmonary embolism. Although the remaining options may be implemented for a client with thromboembolytic disease, the correct option will specifically assist in the prevention of pulmonary embolism.
The nurse is preparing a plan of care for a child diagnosed with leukemia who is beginning chemotherapy. Which intervention should the nurse include?
- A. Monitor rectal temperatures every 4 hours.
- B. Monitor the mouth and anus each shift for signs of breakdown.
- C. Encourage the child to consume fresh fruits and vegetables to maintain nutritional status.
- D. Provide meticulous mouth care several times daily using an alcohol-based mouthwash and a toothbrush.
Correct Answer: B
Rationale: When the child is receiving chemotherapy, the nurse should assess the mouth and anus each shift for ulcers, erythema, or breakdown. The nurse should avoid taking rectal temperatures. Oral temperatures are also avoided if mouth ulcers are present. Axillary or temporal temperatures should be taken to prevent alterations in skin integrity. Bland, nonirritating foods and liquids should be provided to the child. Fresh fruits and vegetables need to be avoided because they can harbor organisms. Chemotherapy can cause neutropenia, and the child should be maintained on a low-bacteria diet if the white blood cell count is low. Meticulous mouth care should be performed, but the nurse should avoid alcohol-based mouthwashes and should use a soft-bristled toothbrush.