Question

A nurse is providing preoperative teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include In the teaching?

Answer 1

Correct Answers:

"You should push the button before physical activity to allow maximum pain control."

Rationale :

💉A patient-controlled analgesia (PCA) pump allows clients to self-administer prescribed doses of pain medication within safe programmed limits.

🏃Pressing the PCA button before physical activity such as ambulation or coughing allows the medication time to take effect and improves pain management during movement.

🚫Pushing the button multiple times does not result in a double dose because the PCA pump has a programmed lockout interval to prevent overdose.

🔒Clients cannot independently adjust medication dosages because only authorized healthcare providers program the PCA settings to ensure safety.

📊Continuous PCA infusion helps maintain more stable plasma medication levels, not fluctuating levels, to improve consistent pain control.

📌Core message

PCA pumps improve pain control by allowing clients to receive medication safely, especially when used before activity to prevent severe pain episodes.

Answer 2

Correct Answers:

“Have your child drink a small glass of water after swallowing the medication."

Rationale :

💊Digoxin is used to improve cardiac function in children with heart failure, and proper administration is essential to avoid toxicity and ensure absorption.

🥤Giving a small amount of water after administration helps ensure the child swallows all the medication completely.

🚫If the child vomits after taking digoxin, the dose should not be repeated without provider instructions because of the risk for toxicity.

🍌Clients taking digoxin should maintain adequate potassium intake because low potassium levels can increase the risk of digoxin toxicity.

🧃Digoxin should not be mixed into a large amount of juice or food because the child may not consume the full dose, leading to inaccurate medication administration.

📌Core message

Safe digoxin administration in children includes ensuring the full dose is swallowed and monitoring for signs of toxicity.

Answer 3

Correct Answers:

Establish an elimination schedule for the client.

Rationale :

🚶Establishing a regular elimination schedule reduces the likelihood that the client will attempt to get out of bed independently, thereby decreasing fall risk.

🛏️Raising all four side rails is considered a form of restraint and can increase injury risk if the client attempts to climb over them.

🔔Bed alarms should remain active even when visitors are present because they provide an important safety alert if the client attempts unassisted ambulation.

⚠️Allowing a client on fall precautions to walk unassisted increases the risk for falls and injury, regardless of proximity to the nursing station.

📌Core message

Effective fall prevention focuses on maintaining safety through scheduled toileting, supervision, and environmental precautions.

Answer 4

Correct Answers:

A history of gastroesophageal reflux disease

Rationale :

🫁Clients with gastroesophageal reflux disease (GERD) are at increased risk for aspiration because stomach contents can reflux into the esophagus and potentially enter the airway.

⚠️Aspiration during enteral feedings can lead to serious complications such as pneumonia, respiratory distress, and impaired oxygenation.

🪑Maintaining the client in a high-Fowler’s position during feedings actually helps reduce aspiration risk by promoting gastric emptying and preventing reflux.

🥣A high-osmolarity formula is more commonly associated with gastrointestinal intolerance such as diarrhea rather than aspiration.

📏A residual volume of 65 mL one hour after feeding is generally considered acceptable and does not independently indicate high aspiration risk.

📌Core message

Clients with GERD receiving enteral feedings require careful monitoring because reflux increases the risk of aspiration.

Answer 5

Correct Answers:

A A-month-old child who is experiencing weight loss

Rationale :

👶Infants with gastroesophageal reflux (GER) who experience weight loss may not be receiving adequate nutrition and require reassessment of their treatment plan.

⚠️Persistent reflux leading to poor weight gain or weight loss can indicate severe GERD requiring further intervention, feeding modifications, or medication adjustments.

🥤A child who recently underwent a Nissen fundoplication and tolerates a full liquid diet demonstrates expected postoperative progress.

🍽️Eating small, frequent meals is an appropriate strategy for managing GER symptoms in older children and adolescents.

💊Taking a proton pump inhibitor before meals is correct because the medication is most effective when administered prior to food intake.

📌Core message

In pediatric GERD, weight loss is an abnormal finding that may indicate ineffective treatment and the need for revised care planning.

Answer 6

Correct Answers:

“This type of seizure can be mistaken for daydreaming:

Rationale :

🧠Absence seizures are brief episodes of impaired consciousness that commonly occur in children and may appear as staring spells or inattentiveness.

👀These seizures are often mistaken for daydreaming because the child may suddenly stop activity, stare blankly, and then quickly resume normal behavior.

⏱️Absence seizures usually last only a few seconds, not 30 to 60 seconds.

⚡They typically have a sudden onset and sudden ending, rather than a gradual onset.

🚫An aura is more commonly associated with focal seizures rather than absence seizures.

📌Core message

Absence seizures are brief episodes that may resemble daydreaming, making early recognition important for treatment and safety.

Answer 7

Correct Answers:

Report the findings to child protective services.

Rationale :

🩹Unexplained bruising in a child can be an indication of possible child abuse or neglect, requiring immediate action by the nurse.

⚖️Nurses are mandated reporters, meaning they are legally required to report suspected abuse to child protective services (CPS) or the appropriate authorities.

🚨The nurse does not need proof of abuse before reporting because the responsibility is to report suspicion, not confirm the abuse personally.

📅Delaying action to arrange meetings with guardians may place the child at continued risk for harm or further injury.

👧Questioning the child’s peers is inappropriate and unreliable and may violate the child’s privacy and safety.

📌Core message

Nurses are mandated reporters and must immediately report suspected child abuse to ensure the child’s safety and protection.

Answer 8

Correct Answers:

Arrange for an ethics committee meeting to address the family’s concerns.

Rationale :

📄An advance directive communicates the client’s healthcare wishes when the client is unable to make decisions independently.

⚖️Healthcare providers are ethically and legally obligated to honor the client’s documented wishes regarding life-sustaining treatment.

🤝An ethics committee meeting helps resolve conflicts between the family’s requests and the client’s advance directives while supporting ethical decision-making.

🚫Initiating life-sustaining measures against the client’s documented wishes violates the principle of autonomy.

📝Completing an incident report is inappropriate because there is no evidence of an error or unexpected event requiring such documentation.

📌Core message

Advance directives protect a client’s right to autonomy, and ethical conflicts should be addressed through appropriate interdisciplinary support.

Answer 9

Correct Answers:

The client reports they get upset with their family members for no apparent reason.

Rationale :

🧠Displacement is a defense mechanism in which emotions are redirected from the original source of stress to a safer or less threatening target.

😠The client expressing anger toward family members without clear cause reflects the redirection of stress-related emotions onto others.

🛡️The statement blaming the partner represents projection, where the client attributes their feelings or behaviors to someone else.

🚫Refusing treatment is more consistent with denial, a defense mechanism involving refusal to acknowledge reality.

📋Bringing a list of questions demonstrates active coping and information-seeking behavior rather than a maladaptive defense mechanism.

📌Core message

Displacement occurs when stressful emotions are redirected toward a safer target instead of the true source of frustration.

Answer 10

Correct Answers:

Assist students in developing a recipe book of healthy foods.
Have teachers and school personnel model healthy eating behaviors.
Provide fruits and vegetables as snacks at school sporting events.

Rationale :

🍎Involving children in creating a healthy recipe book promotes interest in nutritious foods and encourages active participation in healthy eating habits.

👩‍🏫Children often imitate adult behaviors, so having teachers and school staff model healthy food choices positively influences students’ dietary habits.

🥕Providing fruits and vegetables at school activities encourages healthier snack choices and reinforces nutrition education.

🍞Complex carbohydrates are important sources of energy and fiber, so removing them entirely from vending machines is not recommended.

🍰Offering dessert as a reward for finishing meals can create unhealthy relationships with food and reinforce overeating behaviors.

📌Core message

Promoting healthy eating in children involves encouraging positive food choices, healthy role modeling, and active participation in nutrition-focused activities.

1 :
A nurse is providing preoperative teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include In the teaching?

2 :
A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?

3 :
A nurse is caring for a client who is on fall precautions. Which of the following actions should the nurse take?

4 :
A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following factors places the client at risk for aspiration?

5 :
A nurse is planning care for multiple children on a pediatric unit who have gastroesophageal reflux. Which of the following children requires a revision to their plan of care?

6 :
A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?

7 :
A school nurse is assessing a child and notes various bruises on the child's body that are unexplained. Which of the following actions should the school nurse take?

8 :
A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client's family wants the client to have life-sustaining measures. Which of the following actions should the nurse take?

9 :
A nurse is caring for a client who has a new diagnosis of chronic stress. Which of the following findings should the nurse recognize as a manifestation of displacement?

10 :
A school nurse is developing a program to promote healthy eating in school-age children. Which of the following interventions should the nurse include? (Select all that apply.)

1 : A nurse is providing preoperative teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include In the teaching?

2 : A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?

3 : A nurse is caring for a client who is on fall precautions. Which of the following actions should the nurse take?

4 : A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following factors places the client at risk for aspiration?

5 : A nurse is planning care for multiple children on a pediatric unit who have gastroesophageal reflux. Which of the following children requires a revision to their plan of care?

6 : A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?

7 : A school nurse is assessing a child and notes various bruises on the child's body that are unexplained. Which of the following actions should the school nurse take?

8 : A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client's family wants the client to have life-sustaining measures. Which of the following actions should the nurse take?

9 : A nurse is caring for a client who has a new diagnosis of chronic stress. Which of the following findings should the nurse recognize as a manifestation of displacement?

10 : A school nurse is developing a program to promote healthy eating in school-age children. Which of the following interventions should the nurse include? (Select all that apply.)

1 :
A nurse is providing preoperative teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include In the teaching?

2 :
A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?

3 :
A nurse is caring for a client who is on fall precautions. Which of the following actions should the nurse take?

4 :
A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following factors places the client at risk for aspiration?

5 :
A nurse is planning care for multiple children on a pediatric unit who have gastroesophageal reflux. Which of the following children requires a revision to their plan of care?

6 :
A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?

7 :
A school nurse is assessing a child and notes various bruises on the child's body that are unexplained. Which of the following actions should the school nurse take?

8 :
A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client's family wants the client to have life-sustaining measures. Which of the following actions should the nurse take?

9 :
A nurse is caring for a client who has a new diagnosis of chronic stress. Which of the following findings should the nurse recognize as a manifestation of displacement?

10 :
A school nurse is developing a program to promote healthy eating in school-age children. Which of the following interventions should the nurse include? (Select all that apply.)