Question

A nurse in assisting with the plan of care for a client who has peptic ulcer disease. Which of the following interventions should The nurse recommend to include?

Answer 1

Correct Answers:

Monitor the client's stool for occult blood

Rationale :

🟥 Clients with peptic ulcer disease (PUD) are at risk for gastrointestinal bleeding, especially if the ulcer erodes into blood vessels. Monitoring for occult (hidden) blood in stool helps detect early signs of bleeding, which may not be visible but can lead to anemia or hemorrhage.

🟥 Guaiac or fecal occult blood testing (FOBT) is a noninvasive way to assess for slow or ongoing blood loss, especially in hospitalized clients.

🟥 Providing a bedtime snack or placing the client on a clear liquid diet are not standard recommendations for PUD and may worsen symptoms depending on acid production.

🟥 Naproxen is a NSAID, which is contraindicated in PUD because it inhibits prostaglandins that protect the gastric mucosa, increasing the risk for ulcer formation and bleeding.

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Answer 2

Correct Answers:

"You should avoid administering aspirin to your child."

Rationale :

🛑 Aspirin is contraindicated in children, especially during febrile illnesses, due to the risk of Reye's syndrome, a rare but potentially fatal condition that causes acute encephalopathy and liver dysfunction.

🛑 This applies to all forms of aspirin, including baby aspirin, regardless of dose or frequency.

🛑 For fever management in toddlers, acetaminophen or ibuprofen (if age-appropriate) is recommended based on weight and age-specific dosing guidelines.

🛑 Administering an antibiotic for a vaccine-related fever is inappropriate; fevers after immunization are usually mild and self-limiting, not bacterial.

🛑 Educating parents about safe fever management practices is essential to prevent harmful medication use.

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Answer 3

Correct Answers:

Switch to a soy-based formula.

Rationale :

🍼 Bloody stools in an infant drinking cow's milk formula may indicate a cow’s milk protein allergy (CMPA), which can cause intestinal inflammation and bleeding.

🍼 Switching to a soy-based formula is a common first-line alternative for infants with CMPA who are not breastfed, as it avoids bovine proteins that trigger the allergic response.

🍼 Goat’s milk, condensed milk, and unpasteurized milk are not safe alternatives for infants—they lack essential nutrients, may still contain cross-reactive proteins, and pose infection risks.

🍼 The nurse’s recommendation should aim to reduce GI irritation, prevent further bleeding, and support proper infant nutrition and growth.

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Answer 4

Correct Answers:

Periorbital edema

Rationale :

🟣 Periorbital edema (swelling around the eyes) is a classic finding in acute glomerulonephritis, especially noticeable in the morning. It results from fluid retention due to decreased glomerular filtration and sodium and water retention.

🟣 This condition often follows a streptococcal infection and leads to inflammation in the glomeruli, impairing kidney filtration.

🟣 Blood pressure is usually elevated, not decreased, due to fluid overload and vasoconstriction.

🟣 Urine in glomerulonephritis is typically dark, tea-colored, or cola-colored, not pale yellow, due to hematuria.

🟣 Urination is generally decreased (oliguria), not increased, due to reduced kidney function and fluid retention.

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Answer 5

Correct Answers:

Raise the head of the client's bed to 30°.

Rationale :

⚰️ Raising the head of the bed to 30° helps prevent facial discoloration and minimizes pooling of blood (livor mortis) in the face, maintaining a more natural appearance for family viewing.

⚰️ This position also helps keep facial features in place, which is important for dignified presentation during viewing.

⚰️ The nurse should wear clean gloves, not sterile gloves, while performing postmortem care since it is not a sterile procedure.

⚰️ The client’s dentures should be reinserted to help maintain facial shape and appearance, not removed.

⚰️ Gently closing the eyes is standard; surgical tape is not used, as it can appear unnatural or cause trauma to delicate skin.

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Answer 6

Correct Answers:

Moderate pain on the ankle of the affected extremity

Rationale :

🔴 Pain out of proportion to the injury—especially moderate to severe pain not relieved by medication or worsened with passive movement—is a hallmark sign of compartment syndrome.

🔴 This condition occurs when increased pressure within a muscle compartment compromises circulation and nerve function, leading to ischemia and potential tissue death.

🔴 Other classic signs include the 6 P’s: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia (cool limb).

🔴 A warm extremity, normal capillary refill (blanch time), and a palpable pulse do not rule out compartment syndrome—the presence of pulses can be misleading in early stages.

🔴 Pain is often the earliest and most reliable indicator requiring immediate intervention to prevent permanent damage.

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Answer 7

Correct Answers:

Apply continuous pressure to the tip of the child's nose.

Rationale :

🔵 For epistaxis (nosebleed) in children, the appropriate intervention is to apply firm, continuous pressure to the soft lower portion (tip) of the nose for 10–15 minutes to promote clotting.

🔵 The child should be positioned sitting up and leaning slightly forward to prevent blood from flowing down the throat, which could cause nausea, vomiting, or aspiration.

🔵 Tilting the head back or applying a cold compress to the neck is ineffective and unsafe, as it allows blood to pool in the throat.

🔵 Blowing the nose can dislodge clots and worsen bleeding, so it should be avoided during and immediately after an episode.

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Answer 8

Correct Answers:

Inform the family that the client has the right not to take the medication.

Rationale :

⚖️ Clients with major depressive disorder who are alert, oriented, and competent have the legal and ethical right to refuse treatment, including medication.

⚖️ Hiding medication in food without the client's knowledge or consent is a violation of autonomy and can be considered covert medication administration, which is unethical and may be legally actionable.

⚖️ The nurse’s duty is to advocate for the client's rights, ensure informed consent, and promote open communication.

⚖️ If the client continually refuses medication, the nurse should notify the provider for further evaluation, not suggest deceptive practices.

⚖️ Respecting the client’s autonomy is essential in building trusting therapeutic relationships in psychiatric care.

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Answer 9

Correct Answers:

An infant who is postoperative following a cleft palate repair

Rationale :

🗣️ An infant with a history of cleft palate is at high risk for speech and articulation difficulties, even after surgical repair.

🗣️ Speech therapy is essential to support normal language development, improve oral-motor function, and address feeding or swallowing issues that often coexist.

🗣️ Early referral ensures the child meets developmental milestones and receives interventions to minimize long-term communication delays.

🗣️ Children with cystic fibrosis, asthma, or juvenile idiopathic arthritis may require other types of therapy (e.g., respiratory, occupational), but do not typically require speech therapy unless secondary speech issues arise.

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Answer 10

Correct Answers:

Have the client write about life experiences in a journal.

Rationale :

📘 Encouraging the client to write about life experiences helps promote emotional and spiritual expression, address unfinished business, and create a legacy for family members.

📘 This action supports psychosocial comfort and allows the client to reflect on meaning, relationships, and closure as part of end-of-life care.

📘 While favorite foods and family presence may offer comfort, journaling directly addresses the client’s concerns about their family by providing a way to leave memories or messages.

📘 Limiting visits or shifting focus away from the client’s emotional needs does not prioritize their end-of-life goals or concerns.

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QLexNursing

1 :
A nurse in assisting with the plan of care for a client who has peptic ulcer disease. Which of the following interventions should The nurse recommend to include?

2 :
A nurse is preparing to administer required immunizations to a toddler during a well-child visit. The parent asks the nurse how many baby aspirins he should administer if the toddler develops a fever. Which of the following responses should the nurse make?

3 :
A nurse is caring for an infant who is drinking a cow's milk formula and has bloody stools. Which of the following recommendations should the nurse make to the infant's guardian?

4 :
A nurse is collecting data from a child who has acute glomerulonephritis. Which of the following findings should the nurse expect?

5 :
A nurse is providing postmortem care for a client prior to the family viewing the body. Which of the following actions should the nurse take?

6 :
A nurse is collecting data on a client who has swelling of the lower leg. The nurse should identify that which of the following findings is a manifestation of compartment syndrome?

7 :
A nurse is caring for a school-age child who has epistaxis. Which of the following actions should the nurse take?

8 :
A nurse is caring for a client who has major depressive disorder and is refusing their medication. The client's family suggests placing the client's medication in their food. Which of the following actions should the nurse take?

9 :
A nurse is assisting with the discharge plan of care for a group of children. For which of the following children should the nurse recommend a referral for speech therapy?

10 :
A nurse is caring for a client who is nearing the end of life and has concerns about their family. Which of the following actions should the nurse take?

QLexNursing

1 : A nurse in assisting with the plan of care for a client who has peptic ulcer disease. Which of the following interventions should The nurse recommend to include?

2 : A nurse is preparing to administer required immunizations to a toddler during a well-child visit. The parent asks the nurse how many baby aspirins he should administer if the toddler develops a fever. Which of the following responses should the nurse make?

3 : A nurse is caring for an infant who is drinking a cow's milk formula and has bloody stools. Which of the following recommendations should the nurse make to the infant's guardian?

4 : A nurse is collecting data from a child who has acute glomerulonephritis. Which of the following findings should the nurse expect?

5 : A nurse is providing postmortem care for a client prior to the family viewing the body. Which of the following actions should the nurse take?

6 : A nurse is collecting data on a client who has swelling of the lower leg. The nurse should identify that which of the following findings is a manifestation of compartment syndrome?

7 : A nurse is caring for a school-age child who has epistaxis. Which of the following actions should the nurse take?

8 : A nurse is caring for a client who has major depressive disorder and is refusing their medication. The client's family suggests placing the client's medication in their food. Which of the following actions should the nurse take?

9 : A nurse is assisting with the discharge plan of care for a group of children. For which of the following children should the nurse recommend a referral for speech therapy?

10 : A nurse is caring for a client who is nearing the end of life and has concerns about their family. Which of the following actions should the nurse take?

1 :
A nurse in assisting with the plan of care for a client who has peptic ulcer disease. Which of the following interventions should The nurse recommend to include?

2 :
A nurse is preparing to administer required immunizations to a toddler during a well-child visit. The parent asks the nurse how many baby aspirins he should administer if the toddler develops a fever. Which of the following responses should the nurse make?

3 :
A nurse is caring for an infant who is drinking a cow's milk formula and has bloody stools. Which of the following recommendations should the nurse make to the infant's guardian?

4 :
A nurse is collecting data from a child who has acute glomerulonephritis. Which of the following findings should the nurse expect?

5 :
A nurse is providing postmortem care for a client prior to the family viewing the body. Which of the following actions should the nurse take?

6 :
A nurse is collecting data on a client who has swelling of the lower leg. The nurse should identify that which of the following findings is a manifestation of compartment syndrome?

7 :
A nurse is caring for a school-age child who has epistaxis. Which of the following actions should the nurse take?

8 :
A nurse is caring for a client who has major depressive disorder and is refusing their medication. The client's family suggests placing the client's medication in their food. Which of the following actions should the nurse take?

9 :
A nurse is assisting with the discharge plan of care for a group of children. For which of the following children should the nurse recommend a referral for speech therapy?

10 :
A nurse is caring for a client who is nearing the end of life and has concerns about their family. Which of the following actions should the nurse take?