Nokea
While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?
- A. Strange bed and surroundings
- B. Separation from parents
- C. Presence of other toddlers
- D. Unfamiliar toys and games
Correct Answer: B
Rationale: Separation from parents. Separation anxiety is the greatest stress for a toddler during hospitalization.
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Which therapeutic communication skill used by the nurse is most likely to encourage a depressed client to vent feelings?
- A. Direct confrontation
- B. Reality orientation
- C. Projective identification
- D. Active listening
Correct Answer: D
Rationale: Active listening. This skill, along with silence, encourages the client to verbalize feelings.
The nurse is caring for a 3-month-old infant who has bacterial meningitis. Which of the following clinical findings support this diagnosis? Select all that apply.
- A. Depressed anterior fontanelle
- B. High-pitched cry
- C. Poor feeding
- D. Presence of the Babinski sign
- E. Vomiting
Correct Answer: B, C, E
Rationale: High-pitched cry (B), poor feeding (C), and vomiting (E) are signs of bacterial meningitis in infants. A depressed fontanelle (A) suggests dehydration, not meningitis, and Babinski sign (D) is normal in infants.
A client just diagnosed with methicillin-resistant Staphylococcus aureus septic arthritis is receiving the first dose of IV vancomycin. Which finding is most concerning to the nurse?
- A. Diffuse muscle pain
- B. Flushing and pruritus
- C. Low blood pressure
- D. Wheezing and hives
Correct Answer: D
Rationale: Wheezing and hives (D) indicate a possible anaphylactic reaction, the most concerning finding. Muscle pain (A), flushing/pruritus (B), and low blood pressure (C) are less immediately life-threatening.
Diagnosis-related groups (DRGs) provide data to
- A. Identify clients who have specific medical diagnoses
- B. Identify findings related to a medical diagnosis
- C. Determine reimbursement for a medical diagnosis
- D. Implement nursing care based on case management protocol
Correct Answer: C
Rationale: Determine reimbursement for a medical diagnosis. DRGs are the basis of prospective payment plans for reimbursement for Medicare clients.
The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern?
- A. I've felt the need for an afternoon nap most days this week.'
- B. I've gained 3 lb (1.36 kg) since I began taking this medication.'
- C. I've had the stomach flu for the past couple of days.'
- D. My mouth seems to be drier than usual lately.'
Correct Answer: C
Rationale: Stomach flu (C) can cause dehydration, increasing lithium toxicity risk, requiring immediate concern. Naps (A), weight gain (B), and dry mouth (D) are less urgent side effects.