The nurse is caring for a pre-adolescent client in skeletal Dunlop
traction. Which nursing intervention is appropriate for this child?
A) Make certain the child is maintained in correct body alignment.
B) Be sure the traction weights touch the end of the bed.
C) Adjust the head and foot of the bed for the child's comfort
D) Release the traction for 15-20 minutes every 6 hours PRN.
The nurse is assessing a healthy child at the 2 year check up. Which of the
following should the nurse report immediately to the health care provider?
A) Height and weight percentiles vary widely
B) Growth pattern appears to have slowed
C) Recumbent and standing height are different
D) Short term weight changes are uneven
The parents of a 2 year-old child report that he has been holding his breath
whenever he has temper tantrums. What is the best action by the nurse?
A) Teach the parents how to perform cardiopulmonary resuscitation
B) Recommend that the parents give in when he holds his breath to prevent
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anoxia
C) Advise the parents to ignore breath holding because breathing will begin as a
reflex
D) Instruct the parents on how to reason with the child about possible harmful
effects
The nurse is discussing nutritional requirements with the parents of an 18
month-old child. Which of these statements about milk consumption is
correct?
A) May drink as much milk as desired
B) Can have milk mixed with other foods
C) Will benefit from fat-free cow's milk
D) Should be limited to 3-4 cups of milk daily
The nurse is talking with a client. The client abruptly says to the nurse, "The
moon is full. Astronauts walk on the moon. Walking is a good health habit." The
client’s behavior most likely indicates
A) Neologisms
B) Dissociation
C) Flight of ideas
A nurse is doing pre conceptual counseling with a woman who is
planning a pregnancy. Which of the following statements suggests that the
client understands the connection between alcohol consumption and fetal
alcohol syndrome?
A) "I understand that a glass of wine with dinner is healthy."
B) "Beer is not really hard alcohol, so I guess I can drink some."
C) "If I drink, my baby may be harmed before I know I am pregnant."
D) "Drinking with meals reduces the effects of alcohol."
The nurse is assessing a client in the emergency room. Which statement
suggests that the problem is acute angina?
A) "My pain is deep in my chest behind my sternum."
B) "When I sit up the pain gets worse."
C) "As I take a deep breath the pain gets worse."
D) "The pain is right here in my stomach area."
.
The nurse is assessing the mental status of a client admitted with possible
organic brain disorder. Which of these questions will best assess the function
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