Nokea
Marie is a 5-year-old girl is admitted with a diagnosis of Acute Lymphoblastic Leukemia.
Which of the following nursing interventions would be contraindicated to the patient with Leukemia?
- A. Take rectal temperature.
- B. Use soft toothbrush.
- C. Use normal saline for mouthwash TID.
- D. Avoid using dental floss.
Correct Answer: A
Rationale: Rectal temperatures risk rectal injury and infection in neutropenic patients.
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A 12-year-old male is brought to his primary care provider to determine whether sexual abuse has occurred. The mother states, 'Because there is no permanent physical damage, he does not need any more treatment.' The nurse's response should be based on which of the following pieces of information?
- A. Male victims of sexual abuse seldom have long-term psychological problems.
- B. Survivors of male sexual abuse might become confused about their sexual identity.
- C. Unless treated, all male sex abuse survivors grow up to abuse other children.
- D. All children who have been sexually abused have the same needs, regardless of gender.
Correct Answer: B
Rationale: Male sexual abuse survivors may experience confusion about sexual identity, necessitating psychological support. The other statements are incorrect: long-term issues are common, not all survivors become abusers, and needs vary by gender. Psychosocial Integrity
The nurse is monitoring the contractions of a woman in labor. A contraction is recorded as beginning at 10:00 A.M and ending at 10:01 A.M. Another begins at 10:15 A.M. What is the frequency of the contractions?
- A. 14 minutes
- B. 10 minutes
- C. 15 minutes
- D. 9 minutes
Correct Answer: C
Rationale: 15 minutes. Frequency is measured from the start of one contraction to the start of the next.
Thirty minutes after delivery the nurse finds that a mother's uterus is relaxed and the lochia is excessive.
The fist action by the nurse should be to:
- A. Check the mother's vital signs.
- B. Elevate the foot part of the bed.
- C. Immediately notify the physician.
- D. Massage the mother's uterus and expel any clots.
Correct Answer: D
Rationale: Massaging the uterus promotes contraction, reducing excessive lochia and preventing hemorrhage.
When a patient return from the recovery room following a subtotal thyroidectomy, the nurse should immediately
inspect the incision.
- A. instruct the patient not to speak.
- B. keep the patient supine for 24 hours.
- C. place a tracheostomy set at the bedside.
Correct Answer: D
Rationale: Thyroid surgery sometimes results in accidental removal of the parathyroid glands. A resultant hypocalcemia may lead to contraction of the glottis, causing airway obstruction; edema also causes obstruction. Having a tracheostomy set ready is critical.
The nurse is preparing to perform a physical examination on an 8 month-old who is sitting contentedly on his mother's lap. Which of the following should the nurse do first?
- A. Elicit reflexes
- B. Measure height and weight
- C. Auscultate heart and lungs
- D. Examine the ears
Correct Answer: C
Rationale: Auscultate heart and lungs. Performing this during a quiet moment ensures clear sound detection.