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While caring for a child with Reye's syndrome, the nurse should give which action the highest priority?
- A. Monitor intake and output
- B. Provide good skin care
- C. Assess level of consciousness
- D. Assist with range of motion
Correct Answer: C
Rationale: Assess level of consciousness. An altered level of consciousness suggests increasing intracranial pressure related to cerebral edema.
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The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is most likely to experience
- A. high fever
- B. nausea
- C. face and neck edema
- D. night sweats
Correct Answer: B
Rationale: nausea. Because the client with Hodgkin's disease is usually healthy when therapy begins, the nausea is especially troubling.
The nurse on a pediatric unit is caring for a 2-year-old client. Which of the following interventions are appropriate to reduce the distress of hospitalization on the child? Select all that apply.
- A. Encourage the parent to leave the child alone for short intervals
- B. Follow the child’s home sleep schedule and routine
- C. Integrate preferred snack foods into the child’s routine
- D. Point out body changes that may occur
- E. Provide various options when choosing toys
Correct Answer: B,C,E
Rationale: Maintaining sleep routines, offering preferred snacks, and providing toy choices reduce distress by promoting familiarity and autonomy. Leaving alone or discussing body changes may increase anxiety.
A client comes into the community health center upset and crying stating 'I will die of cancer now that I have this disease.' And then the client hands the nurse a paper with one word written on it: 'Pheochromocytoma.' Which response should the nurse state initially?
- A. Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in other parts of the body.
- B. This tumor can be treated effectively with chemotherapy.
- C. Surgery is always required to remove this type of tumor.
- D. This condition is always fatal within a few months.
Correct Answer: A
Rationale: Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in other parts of the body, providing reassurance and accurate information to alleviate the client's fear.
The nurse is reinforcing teaching with a client who has a new prescription for Rh immunoglobulin. The client has an Rh-negative blood type and gave birth 24 hours ago to a newborn who has an Rh-positive blood type. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I need the medication now because the dose I received during pregnancy was ineffective
- B. I can receive the medication at my follow-up appointment in 6 weeks
- C. I need to have a blood specimen obtained in 3 months to verify that the medication was effective
- D. I will receive the medication to prevent my body from forming antibodies
Correct Answer: D
Rationale: Rh immunoglobulin prevents antibody formation against Rh-positive fetal blood, given within 72 hours postpartum. The prenatal dose is separate, 6 weeks is too late, and 3-month testing is not standard.
The nurse is caring for a client with social anxiety disorder. Which of the following situations would most likely exacerbate the client's symptoms?
- A. Shopping in a crowded grocery store
- B. Moving into a new home with the spouse
- C. Speaking in front of peers at a professional convention
- D. Attending an appointment with a new health care provider
Correct Answer: C
Rationale: Speaking publicly, especially to peers, is highly likely to trigger social anxiety due to fear of scrutiny. Crowded stores, moving, and new providers may cause anxiety but are less intense triggers.