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Questions 164

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Question 1 of 5

The nurse is interviewing a 5-year-old client who is reporting abdominal pain. Which of the following are effective strategies for communicating with the child? Select all that apply.

Correct Answer: A,C,E

Rationale: Allowing the child to describe symptoms encourages open communication, and interviewing separately reduces parental influence, ensuring accurate reporting. Closed-ended questions may limit a young child’s ability to express complex symptoms.

Question 2 of 5

The nurse in the mental health unit observes a client hitting the wall repeatedly with the hands after an upsetting family therapy session. The nurse should recognize that the client is exhibiting which of the following defense mechanisms?

Correct Answer: B

Rationale: Defense mechanisms are unconscious mental processes used to protect individuals from uncomfortable thoughts, internal conflicts, and external stresses. Defense mechanisms may be therapeutic to clients with anxiety. However, with excessive use, defense mechanisms may become notherapeutic because they involve a degree of self-deception and reality distortion that can result in poor interpersonal relationships, irrational behavior, and decreased productivity.

Question 3 of 5

A client on the oncology unit is to receive heparin sodium 5 units per kilogram of body weight by subcutaneous route every 4 hours. The client weighs 105.6 lbs. How many units should the client receive in a 24-hour period?

Correct Answer: C

Rationale: The client weighs 48 kg and should receive 5 units/kg, or 240 units every 4 hours. This would be 1440 units in 24 hours. The answers in A, B, and D are incorrect calculations.

Question 4 of 5

The nurse is assessing a client who had a left arm cast applied four hours ago. Which finding indicates that the client may have circulatory impairment?

Correct Answer: B

Rationale: Cold fingers suggest impaired circulation in the casted arm, indicating potential compartment syndrome or vascular compromise, requiring immediate evaluation. Normal blanching, fracture pain, or immobility are less specific.

Question 5 of 5

The nurse is assisting with the care of a newborn during circumcision. Which intervention is appropriate?

Correct Answer: D

Rationale: Wrapping the upper body keeps the newborn warm and secure during circumcision. Sterile technique is required, snug diapers risk irritation, and feeding during the procedure poses a choking risk.

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