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Which of these statements, when made by the nurse, is most effective when communicating with a 4-year-old?
- A. Tell me where you hurt.'
- B. Other children like having their blood pressure taken.'
- C. This will be like having a little stick in your arm.'
- D. Anything you tell me is confidential.'
Correct Answer: A
Rationale: For a 4-year-old, 'Tell me where you hurt' is most effective simple, direct, and age-appropriate, encouraging the child to express pain in their own words, aligning with their concrete thinking stage per Piaget. Option B uses peer pressure, ineffective for this age; C's metaphor may confuse rather than clarify; and D's confidentiality concept is too abstract.
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The nurse is suctioning a client through a tracheal tube. During the procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which should be the nurse's next action?
- A. Notify the registered nurse immediately.
- B. Stop the procedure and oxygenate the client.
- C. Continue to suction the client at a quicker pace.
- D. Ensure that the suction is limited to 15 seconds.
Correct Answer: B
Rationale: A 10-beat heart rate drop during suctioning suggests vagal stimulation or hypoxia; stopping the procedure and oxygenating (B) is the next action to reverse this. Notifying the RN (A) or limiting time (D) follows. Continuing (C) risks worsening. B is correct. Rationale: Suctioning can trigger bradycardia via vagal nerve activation or oxygen depletion; halting and oxygenating restores stability, a critical step per airway management guidelines, preventing further cardiac compromise.
Kenneth, 25 year old diagnosed with HIV felt that he had not lived up with God's expectation. He fears that in the course of his illness, God will be punitive and not be supportive. What kind of spiritual crisis is Kenneth experiencing? 1. Spiritual Pain 2. Spiritual Anxiety 3. Spiritual Guilt 4. Spiritual Despair
- A. 1,2
- B. 2,3
- C. 3,4
- D. 1,4
Correct Answer: B
Rationale: Kenneth faces spiritual anxiety (2) and guilt (3). Anxiety stems from fear of divine punishment, and guilt from feeling he failed God's expectations, per spiritual distress frameworks. Spiritual pain (1) involves loss or meaning, not fear-based here. Despair (4) is hopelessness, not evident as he fears, not resigns. HIV's stigma amplifies 2 and 3, making B (2,3) correct.
A client has a new diagnosis of hyperkalemia and is receiving teaching from a healthcare provider on dietary management. Which of the following statements should the healthcare provider include in the teaching?
- A. You should increase your intake of potassium-rich foods.
- B. You should decrease your intake of potassium-rich foods.
- C. You should avoid foods that contain lactose.
- D. You should increase your intake of dairy products.
Correct Answer: B
Rationale: The correct answer is B: 'You should decrease your intake of potassium-rich foods.' Hyperkalemia is a condition characterized by excess potassium in the blood. To manage hyperkalemia effectively, it is crucial to reduce the intake of potassium-rich foods. This helps in lowering the overall potassium levels in the body and prevents complications associated with hyperkalemia. Choices A, C, and D are incorrect. Increasing the intake of potassium-rich foods (Choice A) would exacerbate hyperkalemia. Avoiding foods that contain lactose (Choice C) is not directly related to managing hyperkalemia. Increasing the intake of dairy products (Choice D) is not recommended as they can be a significant source of dietary potassium.
A group of nurses is participating in a community health fair and is engaged in primary prevention activities. Which activities would these nurses be leading?
- A. Family planning services
- B. Accident prevention education
- C. Heart-healthy nutrition services
- D. Skin cancer screening
Correct Answer: A
Rationale: Primary prevention aims to promote health and stop disease before it starts, a key nursing role at health fairs. Family planning services educate on contraception, preventing unintended pregnancies a proactive health step. Accident prevention education, like teaching helmet use, averts injuries, targeting safety before incidents. Heart-healthy nutrition services promote diets reducing cardiovascular risk, fostering wellness pre-disease. Skin cancer screening, though vital, is secondary prevention, detecting issues early, not preventing onset. Rehabilitation for back pain is tertiary, managing existing conditions. These primary activities planning, safety, nutrition empower communities with knowledge and habits to sidestep illness, aligning with nursing's preventive focus, leveraging education to build health resilience before crises emerge.
A client has a new diagnosis of osteoarthritis and is being taught about dietary management. Which of the following statements should be included in the teaching?
- A. Increase your intake of calcium-rich foods.
- B. Avoid foods that are high in potassium.
- C. Increase your intake of vitamin D-rich foods.
- D. Avoid foods that are high in sodium.
Correct Answer: C
Rationale: The correct statement to include in the teaching is to increase the intake of vitamin D-rich foods. Vitamin D helps improve calcium absorption, which is beneficial for bone health and may help alleviate symptoms of osteoarthritis. Option A is incorrect because while calcium is important for bone health, the focus should be on vitamin D for calcium absorption. Option B is incorrect as potassium is generally not restricted in osteoarthritis. Option D is also incorrect as sodium restriction is more relevant for conditions like hypertension or heart failure, not specifically for osteoarthritis.