Nokea
A child with epiglottitis.
Which of the following nursing observations would indicate to the nurse that a child with epiglottitis is having an early complication of hypoxemia?
- A. Heart rate of 148 beats per minute.
- B. Bluish discoloration of the skin.
- C. Bluish discoloration around the mouth.
- D. Difficulty swallowing.
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to epiglottitis. (1) correct-heart rate correlates with hypoxemia and is an early finding, along with restlessness (2) cyanosis, late sign (3) circumoral cyanosis, late sign (4) sign of epiglottitis
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The nurse in the outpatient clinic teaches the mother of a 10-year-old boy with asthma how to prevent future asthmatic attacks.
- A. Which statement by the mother indicates the nurse should be most concerned?
- B. My son plays the tuba in the grade school band.'
- C. My son loves to help his dad rake leaves.'
- D. My son participates in after-school activities three days a week.'
- E. My son walks one mile to school every day with his friends.'
Correct Answer: B
Rationale: Raking leaves exposes the child to inhaled allergens like pollen and dust, which are primary asthma triggers. Playing the tuba, participating in activities, and walking are unlikely to trigger asthma unless exercise-induced, which is not indicated.
Which individual is at greatest risk for developing hypertension?
- A. 45 year-old African American attorney
- B. 60 year-old Asian American shop owner
- C. 40 year-old Caucasian nurse
- D. 55 year-old Hispanic teacher
Correct Answer: A
Rationale: 45 year-old African American attorney. The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.
A client who has been treated for syphilis.
In preparing discharge plans for a client who has been treated for syphilis, it is MOST important for the community health nurse to include which of the following information?
- A. Practice restraint of sexual activity.
- B. The practice of safe sex.
- C. Information about Planned Parenthood.
- D. Signs of a secondary infection.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not effective in the prevention of transmission of sexually transmitted diseases (2) correct-practice of safe sex, e.g., use of condoms, is primary prevention for transmission of sexually transmitted diseases (3) not as effective in the prevention of transmission of sexually transmitted diseases (4) not as effective in the prevention of transmission of sexually transmitted diseases
A four-month-old child is admitted with a tentative diagnosis of meningitis.
- A. What is the most important nursing action during a lumbar puncture for a four-month-old with suspected meningitis?
- B. Appropriately restrain the child.
- C. Instruct the parents about the procedure.
- D. Provide support to the child.
- E. Elevate the head of the bed.
Correct Answer: A
Rationale: Restraining the child during a lumbar puncture prevents movement, reducing the risk of spinal trauma. Parental instruction and emotional support are important but secondary, and elevating the head is inappropriate for positioning.
An 18-month-old is brought by her father to the well-baby clinic for a routine immunization. Just before the nurse gives the child the injection, the toddler begins to cry.
Which of the following comments by the nurse is the MOST appropriate?
- A. Don't cry. It will be better if you try to behave.'
- B. I know you are frightened. It will be over with soon.'
- C. A big girl like you shouldn't cry. It's only going to hurt a little.'
- D. Please stop crying. There is nothing to be afraid of.'
Correct Answer: B
Rationale: Strategy: Remember therapeutic communication (1) nontherapeutic, doesn't respond to feeling tone and tells child what to do (2) correct-doesn't minimize child's reaction, responds to feeling tone (3) nontherapeutic, minimizes child's reaction (4) nontherapeutic, minimizes child's reaction, should indicate it is OK to feel afraid