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Which of the following actions is appropriate for the nurse to take?
- A. Obtain written consent from the client.
- B. Request verbal consent from the social worker.
- C. Contact the client's parents to obtain phone consent.
- D. Postpone the testing until the client's parents are present.
Correct Answer: A
Rationale: Correct Answer: A. Obtain written consent from the client.
Rationale: Written consent from the client is essential to ensure autonomy and informed decision-making. It shows respect for the client's rights and allows them to fully understand the procedure or treatment. Verbal consent may not provide a legal record of agreement. Contacting the client's parents without the client's consent may violate confidentiality and autonomy. Postponing testing can delay necessary healthcare. Written consent is the most appropriate choice to uphold ethical and legal standards in healthcare practice.
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Which of the following findings should the nurse expect?
- A. Pinpoint pupils
- B. Ataxia
- C. Hyperactive reflexes
- D. Hypothermia
Correct Answer: B
Rationale: The correct answer is B: Ataxia. Ataxia is a neurological finding characterized by lack of coordination and unsteady gait, commonly seen in conditions like cerebellar dysfunction. Pinpoint pupils (A) suggest opioid toxicity, hyperactive reflexes (C) indicate possible hyperthyroidism or CNS injury, and hypothermia (D) is associated with hypothyroidism or hypothermia. Ataxia is the most relevant finding in this context, indicating a potential neurological issue.
Which of the following actions should the nurse take first?
- A. Ask the client if he is considering harming himself.
- B. Encourage the client to attend a group therapy session.
- C. Administer an antidepressant to the client.
- D. Assist the client in completing his ADLs.
Correct Answer: A
Rationale: The correct answer is A. Asking the client if he is considering harming himself should be the first action because it assesses the client's immediate safety. This step is crucial in identifying any potential suicidal ideation and implementing appropriate interventions to ensure the client's well-being. Encouraging group therapy (B), administering medication (C), and assisting with ADLs (D) are important interventions but should come after addressing the client's safety concerns. It is essential to prioritize actions that address the most critical needs first to provide effective and timely care.
Which of the following findings should the nurse identify as a manifestation of severe dehydration?
- A. Capillary refill time 3 seconds
- B. Sunken anterior fontanel
- C. Weight loss of 5%
- D. Produces tears when crying
Correct Answer: B
Rationale: The correct answer is B: Sunken anterior fontanel. This finding is indicative of severe dehydration in infants, as it suggests significant fluid loss and decreased tissue turgor. A sunken fontanel is a late sign of dehydration. Choice A is incorrect as a capillary refill time of 3 seconds is within normal limits. Choice C may be seen in mild to moderate dehydration, but severe dehydration would involve a greater weight loss. Choice D is not specific to dehydration, as tear production can still occur even in cases of dehydration.
The nurse should monitor the child for which of the following complications?
- A. Nuchal rigidity when standing
- B. Double vision
- C. Headache
- D. Pain in the posterior iliac crest
Correct Answer: C
Rationale: The correct answer is C: Headache. In pediatric patients, headaches can be indicative of serious underlying conditions such as meningitis or increased intracranial pressure. Monitoring for headaches is crucial for early detection and intervention. Nuchal rigidity when standing (A) is more indicative of meningitis in adults. Double vision (B) is more associated with neurological issues. Pain in the posterior iliac crest (D) is not typically a complication that requires monitoring in children.
Which of the following findings should the nurse identify as a manifestation of scabies?
- A. Scaly lesions on the inner thighs
- B. Rash with red macular lesions on the scalp
- C. Bull's eye edematous area on the groin
- D. Maculopapular skin burrows on the hand
Correct Answer: D
Rationale: The correct answer is D: Maculopapular skin burrows on the hand. Scabies is caused by the Sarcoptes scabiei mite, which burrows into the skin, causing characteristic burrows that appear as thin, wavy, and slightly raised grayish-white or skin-colored lines. These burrows are commonly found on the hands, fingers, wrists, and interdigital spaces. Scaly lesions on the inner thighs (A) are more indicative of fungal infections. Rash with red macular lesions on the scalp (B) is more suggestive of conditions like seborrheic dermatitis or psoriasis. A bull's eye edematous area on the groin (C) is more characteristic of Lyme disease. In summary, the presence of maculopapular skin burrows on the hand is a key manifestation of scabies, differentiating it from the other options provided.