EAQ Set # 4

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An IV catheter is to be inserted into a 3-year-old toddler's peripheral vein. As local topical anesthetic is applied, the toddler starts to cry and asks whether the insertion is going to hurt. How should the nurse respond? Correct1 "Yes, it will hurt, but not for very long." 2 "Maybe it will hurt, but remember that big kids don't cry." 3 "Yes, it may hurt, but if you hold still it won't hurt too much." 4 "It will hurt a little, but I'm good at getting the needle into your arm."

Although the local anesthetic will help minimize the discomfort, the needle insertion may still hurt. Telling the child that the insertion will hurt but not for very long is an honest, simple answer that is appropriate for a 3-year-old child. Telling the child that big kids don't cry is a judgmental response that is inappropriate for a 3-year-old child; children sometimes need to cry to express their feelings. Although the child should hold still, there is no guarantee that doing this will cause the insertion to hurt less. Saying, "Maybe it will hurt" or "It may hurt" constitutes false reassurance. Saying that the insertion will hurt just a little because the nurse is skilled is also false reassurance; there is no guarantee of success, despite the nurse's self-proclaimed expertise.

Which healthcare system is required after a physical or mental illness, injury, or chemical addiction? Correct1 Rehabilitation 2 Intensive care 3 Psychiatric facilities 4 Extended care facilities

Clients require rehabilitation after a physical illness, mental illness, injury, or chemical addiction. An intensive care unit is required when a client needs close monitoring in addition to medical care. Clients who suffer emotional and behavioral problems such as depression, violent behavior, and eating disorders often require special counseling and treatment in psychiatric facilities. An extended care facility provides intermediate medical, nursing, or custodial care for clients recovering from acute illness or clients with chronic illnesses or disabilities.

According to current statistics, what percent of adolescents try marijuana by the end of high school? Record your answer using a whole number. ________

Current statistics show that by the end of high school, 49% of adolescents experiment with marijuana.

What finding in the client is a sign of allergic rhinitis? 1 Presence of high-grade fever 2 Reduced breathing through the mouth 3 Presence of pinkish nasal discharge 4 Reduced transillumination on the skin over the sinuses

Reduced transillumination on the skin overlying the sinuses indicates allergic rhinitis. This effect is caused by the sinuses becoming inflamed and blocked with thick mucoid secretions. Generally, fever does not accompany allergic rhinitis unless the client develops a secondary infection. In allergic rhinitis, the client is unable to breathe through the nose because it gets stuffy and blocked. Instead the client will resort to mouth breathing. Clients with allergic rhinitis will have clear or white nasal discharge.

A nurse is obtaining a health history from a client with the diagnosis of peptic ulcer disease. Which client statement provides evidence to support the identification of a possible contributory factor? 1 "My blood type is A positive." 2 "I smoke one pack of cigarettes a day." 3 "I have been overweight most of my life." 4 "My blood pressure has been high lately."

Smoking cigarettes increases the acidity of gastrointestinal secretions, which damages the mucosal lining. While blood type O is more frequently associated with duodenal ulcer, type A has no significance. Being overweight is unrelated to peptic ulcer disease. High blood pressure is not directly related to peptic ulcer disease.

A 14-month-old toddler is able to recognize the shapes of objects and fit smaller boxes into larger boxes. Which type of cognitive development does this action indicate? 1 Domestic mimicry 2 Causal relationship 3 Spatial relationship 4 Object permanence

The toddler's ability to recognize the shapes of objects and fit smaller boxes in larger boxes indicates awareness of spatial relationships. If the toddler is acutely aware of others' actions and attempts to copy them in gestures and words, it indicates domestic mimicry. When the toddler explores an object each time it appears in a new place, it indicates an awareness of causal relationships. If the toddler understands that objects continue to exist even when they cannot be observed in the same place, it indicates an awareness of object permanence.

Which statement is true for attachment in the newborn? 1 Attachment occurs for the first 28 days. 2 Attachment begins in the first week of birth. 3 Attachment is the overlapping of soft skull bones. 4 Attachment is the interaction between parent and child.

Attachment is the interaction between the parent and child. The nurse promotes the parents' and newborn's need for physical contact by encouraging breast feeding. Attachment is a process that evolves over the first 24 months. The newborn is awake and alert for the first half-hour after birth, during which parent-child interaction begins. Molding is the overlapping of the soft skull bones commonly seen in newborns that had vaginal births. Molding allows the fetal head to adjust to the various diameters of the maternal pelvis during birth.


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