Question

A nurse is planning care for a preschooler.

Answer 1

Correct Answers:

Alopecia
Tumor lysis syndrome
Hemorrhage
Peripheral neuropathy

Rationale :

🧬Alopecia is a common side effect of chemotherapy agents such as vincristine and doxorubicin due to their action on rapidly dividing cells like hair follicles.

💊Tumor lysis syndrome can occur during the induction phase of leukemia treatment as a result of rapid tumor cell breakdown, leading to electrolyte imbalances and potential renal failure.

💉Hemorrhage risk is elevated due to thrombocytopenia, as the platelet count of 120,000/mm³ is below the normal range, increasing susceptibility to bleeding.

🦶Peripheral neuropathy is a known adverse effect of vincristine, which can damage peripheral nerves, resulting in numbness, tingling, or weakness.

🔬Other options like retinopathy, rheumatoid arthritis, diarrhea, and priapism are not primary or expected complications in the context of ALL treatment with vincristine and doxorubicin.

📌Core Message

Chemotherapy increases risk of alopecia, tumor lysis, bleeding, and neuropathy in children with ALL.

Answer 2

Correct Answers:

Lock the wheels of the bed and the wheelchair.

Rationale :

🔒Locking the wheels of both the bed and the wheelchair prevents unintentional movement and provides stability during transfer.

📏This practice enhances client safety by ensuring a secure base when the client is shifting weight.

🛏️The bed should be raised or lowered to a level where the client’s feet can touch the ground, not solely based on nurse comfort.

🧍A wheelchair should be placed at a 45-degree angle, not 90 degrees, to facilitate easier pivot and transfer.

📌Core Message

Ensure safety and stability by locking wheels during client transfers.

Answer 3

Correct Answers:

"He has an electrical burn. He is stable, and we will update you with any changes."

Rationale :

🗣️This response provides a clear, honest, and reassuring update to the family without making assumptions or sharing complex medical terminology.

📞It also ensures that communication is appropriate and therapeutic, maintaining the client’s privacy and dignity.

💬Providing ongoing updates and maintaining openness is essential when the client is in stable condition but may still be at risk of complications.

⚖️Avoiding terms like “fine soon” or technical phrases like “coagulation of tissues” prevents misunderstanding and distress.

📌Core Message

Use clear, therapeutic communication when updating families about burn injuries.

Answer 4

Correct Answers:

Bradycardia

Rationale :

💓Bradycardia is a common finding in clients with anorexia nervosa due to malnutrition and decreased metabolic rate.

📉This condition reflects the body’s adaptive response to energy conservation during prolonged starvation.

🦷Dental erosion is more associated with bulimia nervosa due to repeated vomiting, not anorexia.

🎧Hyperactive bowel sounds and hypertension are not typically associated with anorexia nervosa, where decreased intake often causes slowed GI motility and low BP.

📌Core Message

Bradycardia is a typical sign of malnutrition in anorexia nervosa.

Answer 5

Correct Answers:

Inspect the mouth for signs of inhalation injuries.

Rationale :

🔥Inhalation injuries take top priority because burns to the face and chest may indicate airway compromise, which can rapidly become life-threatening.

👃Signs such as soot in the mouth or nose, hoarseness, or singed nasal hairs signal potential airway edema.

🩺While pain management, fluid administration, and catheter insertion are necessary, ensuring a patent airway is the most urgent concern.

🚑Delays in airway assessment and intervention can result in airway obstruction as edema progresses.

📌Core Message

Always assess for inhalation injuries first in cases of burns to the face or chest.

Answer 6

Correct Answers:

Peanut butter

Rationale :

🥜Peanut butter is high in phenylalanine, which clients with phenylketonuria (PKU) cannot metabolize due to a genetic enzyme deficiency.

🚫Accumulation of phenylalanine can cause neurological damage, especially during pregnancy, increasing the risk of fetal abnormalities.

🥦Foods like broccoli, apple juice, and potatoes are naturally low in phenylalanine and generally safe in moderation.

👶Clients with PKU require a low-phenylalanine diet throughout life and especially during pregnancy to protect fetal development.

📌Core Message

Clients with PKU must avoid high-phenylalanine foods like peanut butter during pregnancy.

Answer 7

Correct Answers:

Provide a latex-free environment.

Rationale :

🌡️Infants with spina bifida have a high risk of latex allergy, making it essential to create a latex-free environment to prevent anaphylaxis.

🧴Common items like gloves, catheters, and bottle nipples often contain latex and must be replaced with latex-free alternatives.

🛏️Placing the infant in a supine position increases risk of pressure on the myelomeningocele sac, which should be protected preoperatively.

🚪Contact precautions and visitor limitations are not routinely required unless infection control concerns exist.

📌Core Message

Infants with spina bifida require a latex-free environment to prevent allergic reactions.

Answer 8

Correct Answers:

Drink 48 to 64 ounces of water daily.

Rationale :

💧Adequate hydration is essential in clients with mild preeclampsia to promote renal perfusion and reduce risk of hemoconcentration.

🥦Restricting whole grains or raw foods is unnecessary unless otherwise indicated, and such foods are part of a balanced diet.

🍳Protein needs are often increased in preeclampsia to maintain oncotic pressure and reduce edema.

🧂Avoiding salt entirely is not supported; rather, moderation is recommended to manage blood pressure.

📌Core Message

Encourage hydration in preeclampsia to support renal perfusion and fluid balance.

Answer 9

Correct Answers

Blank 1 Correct Option: notify the health care provider
Blank 2 Correct Option: administer pain medications as prescribed

Rationale :

📈The client’s increased pain, abdominal distension, and inability to void may indicate urinary obstruction or complication, requiring provider intervention.

📞Notifying the provider is the first priority, as worsening symptoms could signal renal damage or stone impaction.

💊After notification, administering prescribed pain medication supports comfort while further diagnostics or treatments are arranged.

🏃Encouraging fluids or ambulation is appropriate in early stone passage but not when pain and voiding issues worsen.

📌Core Message

In renal colic with new complications, notify the provider first, then manage pain.

Answer 10

Correct Answers:

Suction saliva from the client's mouth.

Rationale :

🧼Maintaining a patent airway is the highest priority for an unconscious client due to the risk of aspiration and obstruction.

👄Saliva accumulation can lead to airway blockage, particularly in clients unable to swallow or clear secretions.

🧪While monitoring labs, fluid output, and mobility are important, airway clearance takes precedence to sustain oxygenation.

🛌Suctioning is a noninvasive, immediate intervention that reduces risk of aspiration pneumonia.

📌Core Message

Airway clearance is the priority in unconscious clients to prevent aspiration.

1 :
A nurse is planning care for a preschooler.

Answer Options

2 :
A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

3 :
A nurse is caring for a client who has an electrical burn. With the client's permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?

4 :
A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect?

5 :
A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

6 :
A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet?

7 :
A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac? Which of the following interventions should the nurse include in the plan of care?

8 :
A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching?

9 :
A nurse is caring for an adult client in the emergency department.

Correct Answers

10 :
A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?

1 : A nurse is planning care for a preschooler.

Answer Options

2 : A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

3 : A nurse is caring for a client who has an electrical burn. With the client's permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?

4 : A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect?

5 : A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

6 : A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet?

7 : A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac? Which of the following interventions should the nurse include in the plan of care?

8 : A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching?

9 : A nurse is caring for an adult client in the emergency department.

Correct Answers

10 : A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?

1 :
A nurse is planning care for a preschooler.

2 :
A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

3 :
A nurse is caring for a client who has an electrical burn. With the client's permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?

4 :
A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect?

5 :
A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

6 :
A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet?

7 :
A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac? Which of the following interventions should the nurse include in the plan of care?

8 :
A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching?

9 :
A nurse is caring for an adult client in the emergency department.

10 :
A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?