A nurse preparing incoming storm. Which of the following clients should the nurse recommend for discharge planning?

A child who has leukemia and an absolute neutrophil count of 200/mm3 (2.500 to 8.000/mm%)

A child who has a new diagnosis of type diabetes mellitus and is receiving IV insulin

An adolescent who has cystic fibrosis and is receiving their yearly tune-up

An infant who has respiratory syncytial virus and respiratory rate of 70/min

Answer and Explanation

The Correct Answer is B

A) "A child who has leukemia and an absolute neutrophil count of 200/mm³ (2,500 to 8,000/mm³)."
This child is at significant risk for infection due to a severely low neutrophil count, indicating severe neutropenia. Discharge planning for this child would be inappropriate at this time since they need intensive monitoring and care to manage their immunocompromised status and prevent infections.

B) "A child who has a new diagnosis of type 1 diabetes mellitus and is receiving IV insulin."
This child is appropriate for discharge planning. A new diagnosis of type 1 diabetes requires thorough teaching for the family and child about blood glucose monitoring, insulin administration, dietary adjustments, and emergency management. While the child is receiving IV insulin in the hospital, once stabilized, they can be discharged with proper education and support to manage their condition at home.

C) "An adolescent who has cystic fibrosis and is receiving their yearly tune-up."
A cystic fibrosis "tune-up" refers to a period of treatment, often including IV antibiotics and respiratory therapy, to help manage the chronic condition. Since this is part of ongoing care and not an acute issue, discharge planning is not immediately appropriate until the "tune-up" is complete, and the adolescent has stabilized.

D) "An infant who has respiratory syncytial virus (RSV) and a respiratory rate of 70/min."
This infant is at risk for respiratory distress and requires close monitoring. A respiratory rate of 70/min in an infant is elevated, and the child may need additional respiratory support. Discharge planning should not be initiated until the infant's condition improves and they are stable enough to handle care at home.

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Correct Answer is C

Explanation

A) The child is unable to skate with good balance.
At 4 years old, a child’s balance and coordination are still developing. While skating requires more advanced skills, a child not having good balance at this age is not typically a concern unless other motor skills are delayed. Skating is not an expected milestone for a 4-year-old.

B) The child is unable to jump rope.
Jumping rope is a more complex skill that typically develops later, closer to ages 5 or 6, so the inability to do so at age 4 is not a cause for concern. It is a skill that requires fine motor coordination, balance, and timing, which may not be fully developed at this age.

C) The child is unable to walk downstairs on alternating feet.
At 4 years old, children are expected to be able to walk downstairs using alternating feet (one foot on each step). If a child cannot perform this task, it may indicate a delay in gross motor development, specifically in coordination and balance. This is a developmental milestone that typically emerges by age 4 and should be reported to the physical therapist for further evaluation.

D) The child is unable to walk backwards from heel to toe.
Walking backwards from heel to toe is a more advanced skill that typically develops later in childhood. This skill is not expected at age 4, so the child’s inability to do so is not a red flag for developmental concerns. It is more appropriate for older children.

A. Allow the client to have 1 hr of time alone in their room. B. Use short. simple sentences when speaking with the client. C. Ask the client if they would like to watch television. D. Move the client to a table where other clients are playing cards.

Correct Answer is B

Explanation

A) Allow the client to have 1 hour of time alone in their room:
Allowing the client to be alone in their room may not be the best option when they are pacing and wringing their hands, which may indicate anxiety or distress. Rather than isolating them, it is more appropriate to offer support and engage with the client to address the potential underlying anxiety or agitation. Time alone may escalate the feelings of distress rather than provide relief.

B) Use short, simple sentences when speaking with the client:
Using short, simple sentences is an appropriate action when interacting with a client who is pacing and wringing their hands, as this behavior can be indicative of heightened anxiety or agitation. Simple communication reduces confusion and minimizes the cognitive load on the client, helping to keep the interaction clear and calm. It can also help the nurse better assess the client’s feelings and needs in a way that feels less overwhelming to the client.

C) Ask the client if they would like to watch television:
While offering the option of watching television could be an attempt to distract or comfort the client, it does not directly address the potential underlying anxiety or distress the client may be experiencing. It is important to first assess and manage the client’s emotional state before offering distractions like television, which may not effectively address the root of the issue.

D) Move the client to a table where other clients are playing cards:
Moving the client to a group activity may not be the best approach in this situation. The client is demonstrating signs of anxiety or agitation, and suddenly introducing them to a group environment might be overwhelming and could increase their distress. It is more appropriate to first engage the client in a calm, one-on-one interaction using simple communication, and then consider group activities if the client appears ready for them.

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Body system	Findings
Head. Eyes. Ears. Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendancies Insomnia
Genitourinary	Darkening of the urine Urinary frequency

A nurse preparing incoming storm. Which of the following clients should the nurse recommend for discharge planning?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is participating in the care of a 4-year-old child as part of the interdisciplinary team. Which of the following observations should the nurse report to the physical therapist?

Correct Answer is C

Explanation

A nurse working in a mental health facility is caring for a client who is pacing back and forth in the day room while wringing their hands. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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