Nokea
Which statement by the nurse is most therapeutic in addressing the teen's behavior?
- A. There's nothing to be scared of. This won't hurt.
- B. The stitches are strong. They won't come out.
- C. I know you're scared, but you must be brave.
- D. Let's do this later, when you're better prepared.
Correct Answer: C
Rationale: Acknowledging the teen's fear and encouraging bravery validates their emotions while gently motivating them to proceed with ambulation, fostering trust and cooperation.
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Which nursing actions are most appropriate to include in the care plan of a child with nephrotic syndrome? Select all that apply.
- A. Restricting the intake of protein
- B. Weighing the child daily
- C. Completing range-of-motion exercises
- D. Measuring abdominal circumference
- E. Collecting a 24-hour urine specimen
- F. Monitoring blood urea nitrogen (BUN) and creatinine levels
Correct Answer: B,C,D,E,F
Rationale: Daily weighing monitors fluid status, range-of-motion exercises prevent immobility complications, measuring abdominal circumference tracks ascites, collecting urine assesses proteinuria, and monitoring BUN/creatinine evaluates kidney function. Protein restriction is not typical.
Which response by the nurse best explains why aspirin is preferred to acetaminophen (Tylenol) in the treatment of rheumatic fever?
- A. Aspirin controls fever better.
- B. Aspirin prevents infections.
- C. Aspirin relieves joint inflammation.
- D. Aspirin prevents cardiac enlargement.
Correct Answer: C
Rationale: Aspirin is preferred in rheumatic fever due to its anti-inflammatory properties, which relieve joint inflammation and pain associated with polyarthritis. Acetaminophen lacks significant anti-inflammatory effects, making aspirin more effective.
Which information reported by the parents indicates a high risk for the presence of a brain tumor?
- A. The child vomits when first getting out of bed.
- B. The child frequently complains of nausea.
- C. The child forgets where homework is placed.
- D. The child's head tilts toward the side when sleeping.
Correct Answer: A
Rationale: Morning vomiting is a classic sign of increased intracranial pressure from a brain tumor, as pressure is highest after lying flat overnight, making it a high-risk indicator.
Which assessment finding is most indicative of a child with a protein deficiency?
- A. Brittle hair and dry skin
- B. Frequent nosebleeds
- C. High fever and chills
- D. Rapid weight gain
Correct Answer: A
Rationale: Protein deficiency can lead to brittle hair and dry skin due to inadequate protein for tissue repair and maintenance, a hallmark of conditions like kwashiorkor.
Which medication instruction provided by the nurse is most accurate?
- A. Taking your acyclovir as prescribed will prevent the recurrence of lesions.
- B. Your sex partners also need to be treated for 10 days with oral acyclovir.
- C. Use a glove to apply topical acyclovir.
- D. Take the oral acyclovir even when the disease is in remission.
Correct Answer: C
Rationale: Using a glove to apply topical acyclovir prevents self-contamination and virus spread, making it an accurate and safe instruction.