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Exhibits

Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.

Electrocardiogram: Tall T wave and widened QRS complex

Blood pressure: 126/76 mm Hg

Basilar crackles

Urine output: 20 mL in the last hour

Respirations: 26 breaths/minute

Heart rate: 72 beats/minute

Oxygen saturation 98% on room air

A normal body temperature (98.9°F or 37.1°C orally).

Answer and Explanation

Correct Answer : B,F,G,H

A. An electrocardiogram with a tall T wave and widened QRS complex may indicate electrolyte imbalances or cardiac issues, which are not indicative of stabilization.

C. Basilar crackles can be a sign of pulmonary or cardiac issues and are not indicative of stabilization.

D. A urine output of 20 mL in the last hour may suggest reduced kidney function or hydration status and is not indicative of stabilization.

E. A respiratory rate of 26 breaths/minute may indicate respiratory distress and is not indicative of stabilization.

The assessment findings that suggest stabilization include:

A blood pressure within the normal range (126/76 mm Hg).

A heart rate within the normal range (72 beats/minute).

Oxygen saturation of 98% on room air, indicating adequate oxygenation.

A normal body temperature (98.9°F or 37.1°C orally).

These vital signs and clinical parameters are within normal ranges, suggesting that the client's condition is stable at this time.

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Correct Answer is B

Explanation

The intervention the nurse should implement when the child screams and tries to hide behind the parent, dropping a stuffed toy during the collection of the medical history is B.

A. Ignoring the child's behavior and directing questions only to the parent may further distress the child and make them more anxious. It's important to acknowledge the child's feelings and create a supportive environment.

B. Include the child's toy in the collection of information.

Children can become anxious or fearful in healthcare settings, and using strategies to make them feel more comfortable and involved can help build trust. By including the child's toy in the collection of information, the nurse can create a more relaxed and child-friendly atmosphere. This can help the child feel less threatened and more willing to participate in the history-taking process.

C. Documenting interactions between the parent and the child is important for the medical record, but it doesn't address the child's current distress.

D. Obtaining essential information as quickly as possible, without considering the child's comfort and engagement, may not yield the best history and could potentially create resistance and fear in the child.

Therefore, including the child's toy in the process, making the interaction child-friendly, and acknowledging the child's comfort are essential to improve the experience and gather necessary information in a more relaxed atmosphere.

A. Tell the client how to receive a variety of free oral contraceptives from the clinic. B. Encourage the client to discuss her need for contraceptives with her parents. C. Explain that she needs parental approval to receive contraceptives. D. Counsel the client about the risks and benefits of using oral contraceptives

Correct Answer is D

Explanation

While it is essential to prioritize the client's confidentiality and autonomy, it is also important to provide the client with information and education about the available options. In this case:

A. Telling the client how to receive free oral contraceptives from the clinic without addressing the client's need for information and counseling is not an adequate response. It's essential to ensure the client is well-informed about her choices.

B. Encouraging the client to discuss her need for contraceptives with her parents is a valid suggestion, but it may not always be practical or possible for every individual, and the client has already expressed her desire for confidentiality. The nurse should respect the client's autonomy and right to make her own healthcare decisions.

C. Explaining that parental approval is needed to receive contraceptives may discourage the client from seeking essential contraceptive services and may not align with the laws and regulations in many places that allow minors to access contraceptives confidentially.

D. Counseling the client about the risks and benefits of using oral contraceptives is an important step. This allows the client to make an informed decision about her sexual health and contraceptive options. The nurse should also discuss safer sex practices, regular healthcare check-ups, and the importance of open communication with healthcare providers.

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Exhibits Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse begins collecting the medical history of a child when the child screams and tries to hide behind the parent, dropping a stuffed toy. Which intervention should the nurse implement?

Correct Answer is B

Explanation

During her sports physical examination, a 15-year-old female requests oral contraceptives. She explains that she is sexually active and does not want her parents to know. Which action should the nurse take?

Correct Answer is D

Explanation

The nurse is providing treatment education to the caregiver of a school-age child recently diagnosed with attention-deficit/hyperactivity disorder (ADHD). Which statement(s) made by the caregiver demonstrates an understanding of the education? (Select all that apply.)

The parents of a newborn infant with hypospadias are concerned about when the surgical correction should occur. Which information should the nurse provide?

The parents of a 14-month-old child who is hospitalized due to febrile seizures tell the nurse that they fear their child will have lifelong seizures. Which information should the nurse convey to these parents?

A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?

A 3-year-old boy in a daycare facility scratches his head frequently, and the nurse confirms the presence of head lice. The nurse washes the child's hair with permethrin shampoo and calls his parents. Which instruction should the nurse provide to the parents about treatment for head lice?

Exhibits

Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.