EAQ Foundations
How can a nurse BEST meet a preschooler's developmental needs just before a physical examination? A) By allowing the child to handle the examination equipment B) By explaining to the child what will happen during the examination C) By arranging for a peer who has had the same examination to talk to the child D) By requesting that one of the parents stay with the child during the examination
A) By allowing the child to handle the examination equipment Rationale: Handling the equipment permits the child to investigate and become familiar with the instruments.
The nurse manager working at a rehabilitation center for older adults notices an increase in the incidence of client falls. The nurse manager reprimands the nurses and staff responsible for the falls and places them on probation. Which statement BEST describes the nurse manager's leadership style? A) The nurse manager exhibits autocratic leadership. B) The nurse manager demonstrates shared leadership. C) The nurse manager exhibits good clinical leadership skills. D) The nurse manager demonstrates effective interprofessional leadership.
A) The nurse manager exhibits autocratic leadership. Rationale: The nurse manager in this scenario exhibits autocratic leadership. In an autocratic leadership style, all decisions are solely made by the leader. Autocratic leaders are more concerned about the task and may use the threat of punishment to accomplish it.
A nurse in the pediatric clinic is assessing an 8-year-old child who has had asthma since infancy. What clinical finding requires immediate intervention? A) Barrel Chest B) Audible Wheezing C) Heart Rate of 105 beats/min D) Respiratory Rate of 30 breaths/min
B) Audible Wheezing Rationale: Audible wheezing that is heard without a stethoscope is an indication that the airways are significantly comprised, and this requires immediate medical intervention
A nurse is caring for an infant who has just undergone myelomeningocele repair. What should the nursing plan of care include? A) Maintaining a supine position B) Monitoring for cerebrospinal fluid leakage C) Teaching clean catheterizations to parents D) Applying sterile moist dressings to the incision
B) Monitoring for cerebrospinal fluid leakage Rationale: Leakage of cerebrospinal fluid indicates incomplete closure of the defect and must be reported.
The nurse is assessing a client who reports frequent urination. Which inquiry made by the nurse will help determine diabetes insipidus? A) "Do you have history of cancer?" B) "Are you on fluoroquinolone therapy?" C) "Are you on lithium carbonate therapy?" D) "Do you have a history of lymphoma?"
C) "Are you on lithium carbonate therapy?" Rationale: Lithium carbonate is known to interfere with normal kidney response to antidiuretic hormone. Therefore enquiring about lithium carbonate therapy can help assess for diabetes insipidus, which has a clinical manifestation of frequent urination.
A client who is receiving chemotherapy for lung cancer has nausea and vomiting because of the therapy. The client wants to know if it is true that smoking marijuana will help. What is the nurse's best response? A) "Smoking marijuana is not legal in any state" B) "Marijuana is effective for nausea and vomiting if it is injected." C) "Marijuana is not proven to be effective in preventing chemotherapy-induced nausea and vomiting." D) "There are some tetrahydrocannabinol (THC)-based medications that contain marijuana that control chemotherapy-induced nausea and vomiting in some people."
D) "There are some tetrahydrocannabinol (THC)-based medications that contain marijuana that control chemotherapy-induced nausea and vomiting in some people." Rationale: THC, an ingredient in marijuana, acts as an antiemetic in some people and can be absorbed through the gastrointestinal tract or inhaled. THC-based medications, dronabinol (Marinol) and nabilone (Cesamet), are available by prescription to control nausea and vomiting resulting from cancer chemotherapy.
A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the primary healthcare provider? A) Client pushes the airway out. B) Client has snoring respirations. C) Client's respirations are 16 breaths per min and shallow. D) Client's systolic blood pressure drops from 130 to 90 mm Hg
D) Client's systolic blood pressure drops from 130 to 90 mm Hg Rationale: A drop in blood pressure; rapid pulse rate; cold, clammy skin; and oliguria are signs of decreased blood volume and shock, which if not treated promptly can lead to death.
A nurse is obtaining the health history of a 5-year-old child who has been admitted to the child health unit with acute glomerulonephritis. What does the nurse expect the child's mother to report? A) The child has just recovered from the measles B) The child's father has a FHx of UTI C) The child's immunizations were administered at the start of school D) The child had a sore throat a few weeks ago
D) The child had a sore throat a few weeks ago Rationale: Acute poststreptococcal glomerulonephritis (APSGN) is associated with a history of streptococcal infection of the throat.
