Nokea
Which of the following clients should the nurse assess first?
- A. A toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus of nafcillin
- B. An adolescent who is in skin traction and reports a pain level of 7 on a scale from 0 to 10
- C. An adolescent who has sickle cell anemia and slurred speech
- D. A toddler who has a partial-thickness burn on his right hand and requires a dressing change
Correct Answer: C
Rationale: The correct choice is C. The nurse should assess the adolescent with sickle cell anemia and slurred speech first because slurred speech could indicate a potential stroke or other serious neurological complication related to sickle cell disease. It is crucial to prioritize neurological symptoms as they may lead to life-threatening complications if not addressed promptly. Assessing for signs of stroke and providing immediate intervention is essential in this situation. Choices A, B, and D involve pain management and wound care, which are important but not as urgent as addressing potential neurological complications. Therefore, assessing the client with slurred speech is the priority to ensure timely and appropriate intervention.
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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.
Specify 2 actions the nurse should take to address that condition.
- A. Anticipate a prescription for digoxin.
- B. Elevate the head of the bed to a 45° angle.
- C. Implement contact precautions.
- D. Provide chest physiotherapy and postural drainage.
Correct Answer: A,B
Rationale: The correct answers are A and B. A nurse should anticipate a prescription for digoxin as it is commonly prescribed for heart failure to improve heart function. Elevating the head of the bed to a 45° angle helps reduce the workload on the heart and improve respiratory function. Choice C, implementing contact precautions, is unrelated to addressing the condition. Choice D, providing chest physiotherapy and postural drainage, is not typically indicated for heart failure.
Which of the following actions should the nurse take to encourage acceptance of the medication?
- A. Provide an ice pop after administering the medication.
- B. Give 4 oz of milk with the medication.
- C. Mix the medication with the child's favorite food.
- D. Dilute the medication with 8 oz of water.
Correct Answer: A
Rationale: The correct answer is A. Providing an ice pop after administering the medication can create a positive association with taking the medication. The cold sensation and flavor can help mask any unpleasant taste, making the child more likely to accept the medication. Choice B might not be effective as milk may interfere with the medication's absorption. Choice C could work if the child does not detect the medication in the food. Choice D is not ideal as diluting the medication may reduce its effectiveness.
For which of the following adverse effects should the nurse monitor?
- A. Prolonged wound healing
- B. Nausea
- C. Stevens-Johnson syndrome
- D. Renal failure
Correct Answer: B
Rationale: The correct answer is B: Nausea. The nurse should monitor for nausea as it is a common adverse effect of many medications and can impact the patient's overall well-being. Nausea can lead to decreased appetite, dehydration, and noncompliance with medications. Prolonged wound healing (A) is a potential adverse effect but is not as common or immediate as nausea. Stevens-Johnson syndrome (C) is a severe and life-threatening skin reaction that is rare and not typically monitored by nurses. Renal failure (D) is a serious adverse effect but may not be directly related to all medications.
Which of the following findings indicates proper functioning of the child's trigeminal nerve?
- A. The child maintains balance when standing with eyes closed.
- B. The child exhibits a gag reflex when stimulated with a tongue blade.
- C. The child correctly identifies specific scents.
- D. The child has symmetrical jaw strength when biting down.
Correct Answer: D
Rationale: The correct answer is D because symmetrical jaw strength when biting down indicates proper functioning of the trigeminal nerve, which controls the muscles of mastication. Choice A relates to the vestibular system, not the trigeminal nerve. Choice B involves the glossopharyngeal and vagus nerves. Choice C is related to the olfactory nerve.