Question

A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take?

Answer 1

Correct Answers:

Use a designated stethoscope when caring for the toddler.

Rationale :

🔷 Respiratory syncytial virus (RSV) is transmitted through direct contact and large respiratory droplets, not airborne particles.

🔷 Using a designated stethoscope prevents cross-contamination between patients, a key part of contact and droplet precautions.

🔷 The nurse should also wear gloves and a gown while in the room and remove them before exiting to prevent the spread of infection.

🔷 Cohorting or private rooming and use of dedicated equipment are essential strategies for infection control in pediatric clients with RSV.

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Answer 2

Correct Answers:

Provide high-calorie nutritional supplements.

Rationale :

💠 Clients in acute manic episodes often have increased physical activity, poor concentration, and reduced appetite, which can lead to weight loss and nutritional deficits.

💠 High-calorie nutritional supplements help meet their metabolic needs when they’re too distracted or hyperactive to sit for full meals.

💠 Providing finger foods and frequent snacks also supports nutritional intake while accommodating their limited attention span.

💠 This intervention ensures adequate nutrition and hydration, which are crucial for recovery and stability.

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Answer 3

Correct Answers:

Clopidogrel

Rationale :

🔴 Clopidogrel is an antiplatelet medication that inhibits blood clot formation, increasing the risk of bleeding during invasive procedures such as a colonoscopy.

🔴 The bowel mucosa can be easily irritated or damaged during the procedure, and bleeding may be difficult to control if antiplatelet agents are active in the system.

🔴 This medication should typically be discontinued several days prior to procedures involving tissue trauma unless directed otherwise by the provider.

🔴 Reporting this medication use immediately is critical so the provider can evaluate the risk-benefit ratio and determine whether to proceed, delay, or take precautions.

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Answer 4

Correct Answers:

Viewing the newborn's actions to be uncooperative

Rationale :

🔵 Interpreting a newborn’s behavior as uncooperative indicates a misunderstanding of normal infant behavior and may reflect impaired bonding or unrealistic expectations.

🔵 Newborns do not act with intent; behaviors such as crying or moving are neurologically driven and not purposeful misbehavior.

🔵 This perception may interfere with parent-infant attachment, which is critical for emotional development and caregiving responsiveness.

🔵 The nurse should intervene by offering education and emotional support, helping the parent recognize normal newborn cues and fostering positive interaction.

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Answer 5

Correct Answers:

Evening meal
Exercise schedule

Rationale :

💠 Eating late at night, especially after intense activity and close to bedtime, can interfere with sleep by increasing metabolic activity and gastric discomfort.

💠 The client eats dinner after showering post-exercise, which is typically close to bedtime (2330), making digestion and sleep onset more difficult.

💠 Heavy or late meals have been linked to sleep disturbances, especially when consumed within 2–3 hours of sleeping.

💠 The client exercises after 8 PM, which is very close to bedtime, possibly leading to elevated cortisol and adrenaline levels, making it harder to fall or stay asleep.

💠 Evening workouts can delay sleep onset, especially in sensitive individuals, as they can increase alertness and heart rate.

💠 This schedule change correlates with the onset of insomnia-like symptoms, making it a relevant contributor.

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Answer 6

Correct Answers:

Restlessness

Rationale :

🔶 Restlessness is an early neurological sign of hypoxia, caused by reduced oxygen delivery to brain tissue.

🔶 In clients with chronic emphysema, even minor drops in oxygenation can cause subtle behavioral changes like irritability, agitation, or anxiety.

🔶 Identifying restlessness early allows for timely interventions before hypoxia progresses to more severe symptoms.

🔶 As hypoxia worsens, signs such as cyanosis, confusion, and seizures may develop — but restlessness typically appears first.

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Answer 7

Correct Answers:

The preschooler takes tub baths independently.

Rationale :

♦ Independent tub bathing poses a serious safety risk for a preschooler with epilepsy, especially with tonic-clonic seizures, due to the risk of drowning or injury if a seizure occurs while in the bath.

♦ Children with seizure disorders should never be left unsupervised near water, including bathtubs, pools, or toilets.

♦ The nurse should recommend that bathing be supervised and showering be considered safer than tub bathing to minimize risk.

♦ Preventive safety strategies are crucial in home seizure precautions to protect the child during vulnerable activities.

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Answer 8

Correct Answers:

Bilateral lung crackles

Rationale :

🔷 Bilateral lung crackles are a hallmark sign of left-sided heart failure, caused by pulmonary congestion as the left ventricle fails to pump blood efficiently.

🔷 This leads to increased pulmonary capillary pressure, resulting in fluid leakage into the alveoli, which manifests as crackles on auscultation.

🔷 The presence of crackles may indicate worsening cardiac function post-myocardial infarction and requires prompt provider notification.

🔷 Identifying this sign early allows for timely intervention to prevent complications such as pulmonary edema or respiratory failure.

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Answer 9

Correct Answers:

Administer diphenhydramine 50 mg 1M.
Arrange for transport of the client to the nearest emergency department.
Apply cool, wet washcloths to the client's forehead and axilla.

Rationale :

💎 The client shows signs of neuroleptic malignant syndrome (NMS)—a rare, life-threatening reaction to antipsychotic medications. Symptoms include hyperthermia, diaphoresis, altered mental status, and muscle rigidity or dysarthria.

💎 Diphenhydramine may be used as part of symptom management in some NMS cases, especially when extrapyramidal symptoms are also present.

💎 It helps counteract antipsychotic-induced dopaminergic blockade in the brain.

💎 The client needs emergency medical care. NMS is a medical emergency requiring IV hydration, antipyretics, cooling measures, and possibly ICU support.

💎 Prompt recognition and hospital transfer are critical for preventing complications like renal failure, respiratory distress, or death.

💎 Hospitalization enables close monitoring and supportive therapy.

💎 This helps reduce the dangerously high temperature (39.5°C / 103.1°F) through external cooling methods, which is essential in NMS treatment.

💎 Lowering body temperature helps reduce metabolic stress and prevent worsening of systemic symptoms.

💎 Non-pharmacologic cooling is a vital first-line supportive intervention.

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Answer 10

Correct Answers

Blank 1 Correct Option: Kawasaki disease
Blank 2 Correct Option: Plan to administer high dose of aspirin and Provide soft foods
Blank 3 Correct Option: Prolonged bleeding time or daily weights

Rationale :

Plan to administer high dose of aspirin

🟩High-dose aspirin is used in the acute phase to reduce inflammation and prevent thrombosis.

Provide soft foods

🟩Oral mucositis, cracked lips, and tongue inflammation make it painful to eat, so soft foods are easier to tolerate.

Prolonged bleeding time

🟩High-dose aspirin can prolong bleeding; monitor for signs of bleeding complications.

Daily weights

🟩Important to assess for fluid retention or loss, especially if IV immunoglobulin therapy is given or heart function is compromised.

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QLexNursing

1 :
A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take?

2 :
A nurse is planning care for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care?

3 :
A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The client informs the nurse that he took his prescribed medications before coming to the clinic. Which of the following medications is the priority to report to the provider?

4 :
A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?

5 :
A nurse is caring for a client in an outpatient clinic.

Answer Options

6 :
A nurse is assessing a client who has chronic emphysema. The client is receiving oxygen at 2 Limin via nasal cannula and is resting with the head of bed elevated to a 4so angle. Which of the following findings should the nurse identify as an early indication of hypoxia?

7 :
A nurse is performing a home assessment for a preschooler who has a new diagnosis of epilepsy with tonic-clonic seizures. For which of the following findings should the nurse recommend modifications?

8 :
A home health nurse is assessing a client who is recovering from an acute myocardial infarction (MI). Which of the following assessment findings should the nurse report to the provider as a possible indication of left-sided heart failure?

9 :
A nurse is caring for a client.

Answer Options

10 :
A nurse is caring for a 6-year-old child in an emergency department.

Correct Answers

QLexNursing

1 : A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take?

2 : A nurse is planning care for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care?

3 : A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The client informs the nurse that he took his prescribed medications before coming to the clinic. Which of the following medications is the priority to report to the provider?

4 : A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?

5 : A nurse is caring for a client in an outpatient clinic.

Answer Options

6 : A nurse is assessing a client who has chronic emphysema. The client is receiving oxygen at 2 Limin via nasal cannula and is resting with the head of bed elevated to a 4so angle. Which of the following findings should the nurse identify as an early indication of hypoxia?

7 : A nurse is performing a home assessment for a preschooler who has a new diagnosis of epilepsy with tonic-clonic seizures. For which of the following findings should the nurse recommend modifications?

8 : A home health nurse is assessing a client who is recovering from an acute myocardial infarction (MI). Which of the following assessment findings should the nurse report to the provider as a possible indication of left-sided heart failure?

9 : A nurse is caring for a client.

Answer Options

10 : A nurse is caring for a 6-year-old child in an emergency department.

Correct Answers

1 :
A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take?

2 :
A nurse is planning care for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care?

3 :
A nurse is performing an admission assessment for a client who is to undergo a colonoscopy. The client informs the nurse that he took his prescribed medications before coming to the clinic. Which of the following medications is the priority to report to the provider?

4 :
A nurse is observing bonding between a client and her newborn. Which of the following actions by the client requires the nurse to intervene?

5 :
A nurse is caring for a client in an outpatient clinic.

6 :
A nurse is assessing a client who has chronic emphysema. The client is receiving oxygen at 2 Limin via nasal cannula and is resting with the head of bed elevated to a 4so angle. Which of the following findings should the nurse identify as an early indication of hypoxia?

7 :
A nurse is performing a home assessment for a preschooler who has a new diagnosis of epilepsy with tonic-clonic seizures. For which of the following findings should the nurse recommend modifications?

8 :
A home health nurse is assessing a client who is recovering from an acute myocardial infarction (MI). Which of the following assessment findings should the nurse report to the provider as a possible indication of left-sided heart failure?

9 :
A nurse is caring for a client.

10 :
A nurse is caring for a 6-year-old child in an emergency department.