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Which response by the nurse would be most helpful in this situation?
- A. You should attempt to discuss the dangers of drug abuse with the patient to see if treatment is necessary.
- B. It will be necessary to get a court order before you can force your child to enter a drug treatment program.
- C. The success of the drug treatment program will depend on your child's desire to become drug-free.
- D. It's best that you force your child into the treatment program because otherwise participation probably will not occur.
Correct Answer: C
Rationale: The success of drug treatment relies on the adolescent's motivation to recover, making it important to discuss their willingness and readiness for treatment.
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Duration of latent phase in a multigravida is:
- A. 1-2 hours.
- B. 2-4 hours.
- C. 4-6 hours.
- D. 6-8 hours.
- E. 8-10 hours.
Correct Answer: C
Rationale: The latent phase in multigravida typically lasts 4-6 hours shorter than in primigravida due to prior cervical changes. Other durations are less common.
Which assessment finding should the nurse report immediately to the charge nurse or physician?
- A. Clear, watery nasal drainage
- B. Glasgow Coma Scale score of 15
- C. Child does not know the time of day
- D. Apical pulse of 80 beats/minute
Correct Answer: A
Rationale: Clear, watery nasal drainage may indicate cerebrospinal fluid (CSF) leakage, a serious complication of head injury requiring immediate reporting to prevent infection or neurological damage.
Which statement by the client indicates that teaching has been effective?
- A. My partner should use a condom when lesions are present to prevent transmission.
- B. I should douche after intercourse to prevent becoming infected.
- C. I should apply acyclovir to lesions before intercourse to prevent transmission.
- D. I should avoid sexual contact, especially when lesions or symptoms are present.
Correct Answer: D
Rationale: Avoiding sexual contact when lesions or symptoms are present is the most effective way to prevent herpes transmission, indicating successful teaching.
While caring for the small-for-gestational-age newborn (SGA),the nurse notes slight tremors of the extremities a high-pitched cry and an exaggerated Moro reflex. In response to these assessment findings what should be the nurse’s first action?
- A. Assess the infant’s blood sugar level.
- B. Document the findings in the infant’s medical record.
- C. Immediately inform the pediatrician of the symptoms.
- D. Assess the infant’s axillary temperature.
Correct Answer: A
Rationale: SGA infants risk hypoglycemia due to low glycogen stores causing tremors high-pitched cry and exaggerated reflexes. Checking blood sugar is the priority action.
Which nursing action is most appropriate when caring for a school-age child who is experiencing a nosebleed?
- A. Tilt the child's head backward, and apply an ice pack to the nose.
- B. Position the child's head forward while gently pinching the nostrils.
- C. Pack the affected nostril with a small amount of clean cotton.
- D. Clean the affected nostril, and instill saline nose drops.
Correct Answer: B
Rationale: Positioning the head forward and pinching the nostrils applies pressure to stop bleeding while preventing blood from flowing down the throat, which could cause choking or nausea.