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1. A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, 'I don't understand why my child is so upset. I've never seen my child act this way around others before.' Which of the following statements should the nurse make?
- A. This is a normal, expected reaction for a child of this age.
- B. This is a response to an overstimulating environment.
- C. This is a common reaction to an overexposure to caregivers.
- D. This is a typical reaction for a child who is sick.
Correct answer: A
Rationale: The correct answer is 'This is a normal, expected reaction for a child of this age.' Separation anxiety typically peaks around 8-10 months of age, leading to distress when separated from caregivers. Choice B is incorrect because the infant's behavior is more likely due to separation anxiety rather than overstimulation. Choice C is incorrect as the infant's behavior is not related to overexposure to caregivers but rather a natural developmental stage. Choice D is incorrect as the infant's behavior is not indicative of illness but rather a normal emotional response.
2. Most nurses regard this conventional recording of the date, time, and mode by which the patient leaves a healthcare unit but this record includes importantly, directs of planning for discharge that starts soon after the person is admitted to a healthcare institution. It is accepted that collaboration or multidisciplinary involvement (of all members of the health team) in discharge results in comprehensive care. What do you call this?
- A. Discharge Summary
- B. Nursing Kardex
- C. Medicine and Treatment Record
- D. Nursing Health History and Assessment Worksheet
Correct answer: C
Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.
3. Does alcohol contain energy and is therefore a nutrient?
- A. True
- B. False
- C.
- D.
Correct answer: B
Rationale: Alcohol does contain energy and provides calories, but it is not considered a nutrient. Nutrients are substances that contribute to essential bodily functions. While alcohol may have energy, it does not provide essential vitamins, minerals, or other nutrients necessary for the body's health. Additionally, excessive alcohol consumption can have harmful effects on the body, further supporting why alcohol is not classified as a nutrient.
4. A child with ear problem should be assessed for the following, EXCEPT:
- A. is there any fever?
- B. Ear discharge
- C. If discharge is present for how long?
- D. Ear pain
Correct answer: A
Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.
5. A nurse is initiating continuous enteral feedings for a client who has a new gastrostomy tube. Which of the following actions should the nurse take?
- A. Measure the client’s gastric residual every 12 hours.
- B. Obtain the client’s electrolyte levels every 4 hours.
- C. Keep the client’s head elevated at 15° during feedings.
- D. Flush the client’s tube with 30 mL of water every 4 hours.
Correct answer: D
Rationale: Flushing the client’s tube with 30 mL of water every 4 hours is essential to maintain tube patency and prevent blockages. This action helps ensure the continuous flow of enteral feedings without obstruction. Measuring the client’s gastric residual every 12 hours (Choice A) is important but not the priority when initiating enteral feedings. Obtaining the client’s electrolyte levels every 4 hours (Choice B) is unnecessary and not directly related to tube feeding initiation. Keeping the client’s head elevated at 15° during feedings (Choice C) is a good practice to prevent aspiration, but tube flushing is more crucial to prevent tube occlusion.
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